Severe Personality Disorders

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Severe Personality Disorders

This book is about understanding and managing patients with severe personality disorders. It covers biological, psychoanalytic and cognitive behavioral approaches and provides a pragmatic guide to best practice, based on the published evidence, where this is available. As well as discussing issues of severity, treatability and the range of appropriate management options, the content explores the common elements of effective interventions and covers early prediction, countertransference, disruptions of the therapeutic alliance, suicidal crises and what to do when dealing with dangerous, refractory and stalking patients. The chapters are authored by an international cast of distinguished investigators and innovators from the field. This is a holistic, practical guide to the treatment of patients with a range of these disorders and it should be read by all the members of the mental health team dealing with this challenging clinical group. Bert van Luyn is Clinical Psychologist and Clinical Head of Transmural Services for Longterm Psychiatric Disorders, Symfora Groep, The Netherlands. Salman Akhtar is Professor of Psychiatry at Jefferson Medical College and Supervising and Training Analyst at the Psychoanalytic Center of Philadelphia, USA. W. John Livesley is Professor Emeritus in the Department of Psychiatry, University of British

Columbia, Canada.

Severe Personality Disorders Edited by

Bert van Luyn Symfora groep, Amersfoort

Salman Akhtar Department of Psychiatry, Jefferson Medical College, Philadelphia

W. John Livesley Department of Psychiatry, University of British Columbia, Vancouver

CAMBRIDGE UNIVERSITY PRESS

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521856515 © Cambridge University Press 2007 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2007 eBook (EBL) ISBN-13 978-0-511-35490-8 ISBN-10 0-511-35490-8 eBook (EBL) ISBN-13 ISBN-10

hardback 978-0-521-85651-5 hardback 0-521-85651-5

Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this publication to provide accurate and up-todate information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

To Henk-Jan Dalewijk Colleague, friend and benefactor

Contents

List of contributors Preface 1

Treatability in severe personality disorders: how far do the science and art of psychotherapy carry us?

page ix xi

1

Michael H. Stone

2

The treatment of choice: what method fits whom?

30

John F. Clarkin

3

Countertransference: recent developments and technical implications for the treatment of patients with severe personality disorders

42

Otto F. Kernberg

4

Beyond management to cure: enhancing the positive dimensions of personality

59

C. Robert Cloninger

5

Personality disorders from the perspective of child and adolescent psychiatry

79

Arnold Allertz and Guus van Voorst

6

Disruptions in the course of psychotherapy and psychoanalysis

93

Salman Akhtar

7

Managing suicidal crises in patients with severe personality disorders

109

Joel Paris

8

Borderline personality disorder, day hospitals, and mentalization

118

Anthony W. Bateman and Peter Fonagy

9

Pharmacotherapy of severe personality disorders: a critical review Thomas Rinne and Theo Ingenhoven

vii

137

viii

Contents

10

Severe cases: management of the refractory borderline patient

164

Bert van Luyn

11

Dangerous cases: when treatment is not an option

181

J. Reid Meloy and James A. Reavis

12

Stalking of therapists

196

Paul E. Mullen and Rosemary Purcell

13

Common elements of effective treatments

211

W. John Livesley

Index

240

Contributors

Salman Akhtar, M.D. Professor of Psychiatry Jefferson Medical College Supervising and Training Analyst Psychoanalytic Center of Philadelphia Philadelphia, PA, USA Arnold Allertz, M.D. Managing Director Fornhese, Department of Child & Adolescent Psychiatry, and Emerhese, Center for Autistic Disorders Symfora groep, Centers for Mental Health Amersfoort, The Netherlands Anthony W. Bateman, FRCPsych Consultant Psychiatrist and Psychotherapist Halliwick Unit, Barnet, Enfield, and Haringey Mental Health Trust Visiting Professor University College, London, UK John F. Clarkin, Ph.D. Clinical Professor of Clinical Psychology in Psychiatry Co-Director, Personality Disorders Institute Weill Medical College of Cornell University New York, NY USA C. Robert Cloninger, M.D. Wallace Renard Professor of Psychiatry Genetics, and Psychology ix

Director, Sansone Family Center for Well-Being Washington University School of Medicine St. Louis, MO, USA Peter Fonagy, Ph.D. FBA Freud Memorial Professor of Psychoanalysis Director Sub-Department of Clinical Health Psychology Chief Executive Anna Freud Centre University College London London, UK Theo Ingenhoven, M.D. Clinical Head De Zwaluw and De Enk, Centers for Psychotherapy for Personality Disorders Symfora groep, Centers for Mental Health Amersfoort, The Netherlands Otto F. Kernberg, M.D. Professor of Psychiatry Director Personality Disorders Institute Weill Medical College of Cornell University New York Presbyterian Hospital Training and Supervising Analyst Colombia University Center for Psychoanalytic Training and Research New York, NY, USA W. John Livesley, M.B., Ch.B., Phd., FRSC Professor Emeritus Department of Psychiatry

x

Contributors

University of British Columbia Vancouver, Canada Bert van Luyn Clinical Psychologist Clinical Head Transmurale Langdurige Psychiatrie, Transmural Services for Patients with Long-term Psychiatric Disorders Director Psychiatrie in Progressie, a Program of Postgraduate Education in Psychiatry and Psychotherapy Symfora groep, Centers for Mental Health Amersfoort, The Netherlands J. Reid Meloy, Ph.D. Associate Clinical Professor of Psychiatry University of California San Diego, CA, USA Adjunct Professor University of San Diego School of Law San Diego, CA, USA President, Forensis San Diego, CA, USA Paul E. Mullen, M.B. B.S., DSc., FRANZCP, FRCPsych Professor of Forensic Psychiatry Monash University Clinical Director Victorian Institute of Forensic Mental Health Melbourne, Australia Joel Paris, M.D. Professor of Psychiatry McGill University Research Associate SMBD-Jewish General Hospital Montreal, Qu´ebec, Canada

Rosemary Purcell M Psych, Ph.D. Senior Research Fellow ORYGEN Research Centre The Department of Psychiatry The University of Melbourne Victoria, Australia James A. Reavis, Psy.D. Director of Forensic Services Relationship Training Institute San Diego, CA, USA Thomas Rinne, M.D., Ph.D. Scientific Director Dutch Institute of Forensic Psychiatry and Psychology Member of the Board Medical Director Pieter Baan Centrum, Forensic Psychiatric Observation Clinic Utrecht, The Netherlands Michael H. Stone, M.D. Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons New York City Attending in Psychiatry and former Research Director Mid-Hudson Forensic Psychiatric Center, retired New Hampton, NY, USA Guus van Voorst Clinical Psychologist Clinical Head Emerhese, Center for Autistic Disorders Symfora groep, Centers for Mental Health Amersfoort, The Netherlands

Preface

This book is about the understanding and treatment of severe personality disorders. The essays contained in it are all original, having been written specifically for this volume. The thrust is essentially clinical and pragmatic, based on best practice, and, whenever possible, the best evidence. Eschewing biological, psychoanalytic and cognitive behavioral theories, the book focuses upon issues of day-to-day management of patients with severe personality disorder. The topics covered range from early predictors, treatability, common elements of effective therapies, psychopharmacological interventions, countertransference, disruptions of the therapeutic alliance, and suicidal crises, to the management of the dangerous, refractory, and stalking patient. The book is a collective effort by distinguished investigators and innovators in the field of severe personality disorders. A common link among them is that they all have been involved with “Psychiatrie in Progressie,” a postgraduate educational program of Zon and Schild, a Dutch psychiatric hospital, now part of the Symfora groep. The book is a tribute to Henk-Jan Dalewijk, who until 2005 was Executive Director of the Symfora groep. As a psychiatrist and administrator, he enabled the development of excellent teaching programs on psychiatry and psychotherapy, inspiring all the friends and colleagues who contributed to this volume. The book comprises 13 chapters. In the first chapter, Michael H. Stone, an early researcher on the course and outcome of personality disorders, addresses one of the major issues of everyday practice: severity and treatability. Stone argues that the most ominous, “severe” personality disorders, such as antisocial or paranoid personality disorder, are not necessarily the most difficult to treat. A severe avoidant patient may be much more challenging. Stone reviews contemporary follow-up research on severe personality disorder, and discusses the numerous factors that influence amenability to psychotherapy; for example, age, work history, the main personality configuration, intensity of traits, psychological mindedness and mentalization, empathy, attachment style, concomitant symptom disorders and their severity, the skill of the therapist with a particular type of patient, matching, etc. In spite of the growing number of studies, Stone argues, we still do not know what xi

xii

Preface

particular patient will respond best to what type of approach, and we still have to rely heavily on expert opinion. In his contribution, John F. Clarkin thoughtfully elucidates the dilemmas of selecting the proper treatment strategy once treatment is indicated. He notes the difference in therapeutic approaches available and how the difficulty of choosing a particular form of treatment is compounded by the fact that patients vary greatly in their motivation, attachment patterns, and mentalization capacities. Attempting to control the therapist-related variables, which he acknowledges also play a role, Clarkin offers two clinical illustrations to highlight the workings of transferencebased therapy and its effects. His contribution paves the way for further conceptual research for finding solid guidelines for differential therapeutics in this realm. Next, Otto F. Kernberg provides a succinct yet thorough elucidation of the countertransference reactions experienced by therapists dealing with individuals with severe personality disorders. Anchoring his views in object relations theory, Kernberg demonstrates how the boredom, sleepiness, development of blind spots, and sadomasochistic enactments on the therapist’s part reflect the impact of the patient’s psychopathology. He distinguishes between acute and chronic countertransference reactions and notes that many self-destructive patients also unconsciously attempt to destroy the therapeutic situation. In all these realms, Kernberg offers guidelines for vigilance, self-observation, and maintenance of a therapeutic position vis-`a-vis the patient. Eschewing the traditional emphasis upon the negative aspects of personality disorder, C. Robert Cloninger focuses on the development of well-being. For him, the absence of positive personality features is the cornerstone of the dynamic understanding of these disorders. He also emphasizes that efforts to develop such features ought to be central to the therapeutic approach for patients with severe personality disorders. One may not fully agree with his optimistic emphasis, but he offers an intriguing and novel perspective on the nature and care of severe personality disorders. More psychopathological aspects of development are discussed by Arnold Allertz and Guus J. P. van Voorst. While most chapters of this book deal with how one might help to end, or at least ameliorate, personality problems, they wonder when personality disorder begins – currently a topic of considerable debate – and whether there is psychopathological continuity over time. From their perspective of child and adolescent psychiatry, they give an overview of what early factors might contribute to later personality dysfunction. They discuss the possible effects of early maltreatment, problems in attachment, prenatal stress in the mother, and try to relate childhood psychopathology to later Axis II disorders. Given the lack of specificity of all kind of predictive markers, they tend to support the traditional cautiousness of child and adolescent psychiatry in using personality disorder diagnoses.

xiii

Preface

The treatment of patients with severe personality disorder rarely goes smoothly. Disturbed relationships are an inherent feature of these disorders and therapy is not immune from the effects of relationship problems of these patients. These disorders typically confront the therapist with crises and disruptions of the therapeutic alliance. Successful management of these disruptions and ruptures to the alliance is often a key factor in successful treatment. Salman Akhtar explores how disruptions emerge, how they can be understood, and how they can be repaired. He considers both patient and therapist contributions to these problems. In patients with severe personality disorder, internal deficits (“not knowing how to be”) are often at the core of therapeutic disruptions. Their developmental history of lack of love, chronic neglect, and abuse often fills these patients with hurt and hatred and fuels an intrapsychic conflict of desperately seeking support while at the same time wanting to attack their caretaker. Using appealing clinical vignettes, Akhtar describes the different ways in which disruptions are manifested ranging from momentary disruptions of working alliance to broken therapeutic boundaries and threats of physical harm. At the same time, Akhtar elucidates a series of different psychotherapeutic techniques that directly deal with disruptions. In spite of their threatening potential, Akhtar concludes with an interesting developmental perspective on disruptions. Disruptions are not all bad: “. . . developmentally speaking, disruption is not an exception but a rule.” Disruptions often proceed and facilitate the development of new tasks, new insights, growth, and as such are a necessary part of the therapeutic endeavor. In the subsequent chapter, Joel Paris, who has written extensively on borderline patients and is well-versed in the language of their despair, tackles the management of suicidal crises. Writing in a succinct and, at times, wry fashion, Paris raises doubts about the therapeutic utility of short-term hospitalization under such circumstances. This is especially because most suicides do not occur during a crisis situation and threat-induced hospitalizations have the potential of causing greater regression and gratifying infantile expectations. However, admitting a patient after a life-threatening suicide attempt can be valuable insofar as it might provide an opportunity to assess psychosocial stressors and to re-evaluate the treatment plan. In general, however, therapists dealing with a borderline patient should focus less on acute crisis than on the chronic distress that underlies it. In their chapter on the role of day hospital in the treatment of borderline patients, Anthony W. Bateman and Peter Fonagy suggest that more “intense” treatments might stimulate rather than ameliorate their difficulties because of the destabilizing effects of their emotional intensity. They suggest that a day hospital offers a level of affect that is intermediate between inpatient and outpatient settings and thus constitutes an ideal setting for treating borderline patients. The authors elucidate the various strategies that constitute optimal care under such circumstances and lead

xiv

Preface

to enhanced mentalization of inner states by the usually overwhelmed borderline patient. Such techniques need to be offered in the context of a positive attachment relationship and consistently applied over a course of time. Mentalization strengthens attachment, and a secure attachment, in turn, facilitates mentalization. Though pills do not change character, they are often useful agents in managing personality disorder. Thomas Rinne and Theo Ingenhoven, two Dutch psychiatrists, provide a thorough and thoughtful survey of the pertinent literature. Noting the conceptual biases and methodological flaws in many studies of the efficacy of medication and the inherent difficulties in such undertakings, they consider the role of medications in treating specific problems such as aggressiveness, impulsivity, affect deregulation, and psychotic-like symptoms. Thoughtful and cautious in their handling of the issues involved, they nonetheless provide clear guidelines that clinicians will find useful when deciding how to treat their patients. They are explicit about what has been established, what is conjecture, what is unreasonable optimism, and what is needed to develop a sound understanding of the contribution that medication can make as part of an overall treatment plan. Bert van Luyn, and J. Reid Meloy and James A. Reavis tackle the difficult and challenging problems of refractory and dangerous cases. Van Luyn describes a management strategy for the refractory borderline patient. Referring to the severity and chronic nature of their illness, he claims that long-term assertivecommunity-treatment-like programs fit their capricious profile best. Acknowledging the inevitability of extended admissions for these patients, his strategy involves integrated inpatient and outpatient services. Psychoeducation, outreaching and rehabilitation facilities, training on the spot, and team support are key elements in this approach. In van Luyn’s view, there is an important role for a psychotherapeutically trained professional in such an integrated program. More or less independent from the treatment setting, this professional “follows” the patient and helps them “mentalize,” understand what happens, recognize behavioral patterns, and develop better strategies to fulfil his or her needs. Great emphasis is placed on developing a collaborative alliance. Severe personality disorder in the form of psychopathy is discussed by Meloy and Reavis. Like any other personality disorder, psychopathy may vary from mild to severe. Though patients with psychopathy or psychopathic features are not the everyday patient, we all may meet them in clinical practice. Meloy and Reavis argue that the clinician better be careful: treatment of the severely psychopathic patient is difficult and may even increase the risk of future criminal behavior. There was certainly evidence of this in evaluations of early treatments based on therapeutic community models; more structured treatments however have not been systematically evaluated. Perhaps the only conclusion is that currently we simply do not know whether psychopathy is treatable using contemporary treatment strategies.

xv

Preface

Given the nature of severe psychopathology Meloy’s and Reavis’ warning not to underestimate the danger of the psychopathic patient in general clinical settings is well-taken: psychopathy is the best predictor of violence in forensic and civil populations. Moreover, discerning the psychopathic core may not be so easy, since psychopathic patients are often very skilful in imitating the more mature emotional states that they observe the therapist wants them to feel. Meloy and Reavis address this problem by listing some typical countertransference reactions that may be sensitive indicators of this disorder that would warrant objective testing. They also offer valuable parameters to manage the risk involved once treatment is undertaken. Paul E. Mullen and Rosemary Purcell deal with another difficult patient: the patient who stalks his or her therapist: a less uncommon phenomenon than we might think. Stalking of therapists is usually not restricted to brief intense periods of harassment lasting only a few days but unfortunately tends to involve a pattern of stalking that is more extended and far more damaging. It usually emerges from the patient’s misplaced desire to establish an intimate relationship with the therapist or from feelings of resentment or anger for some actual or supposed injury. Stalkers of therapists are more likely to be male with a primary diagnosis of personality disorder. Mullen and Purcell warn for the temptation to look for technical and professional failings in the therapist: stalking therapists is an inherent risk in treatment, not therapeutic ineptitude. If faced with this situation, they advise not to retreat in rationalizations, denial, or empathic understanding but to share the concerns with colleagues, ask for professional and practical support, transfer the patient, inform relatives, and keep detailed records of all unwanted contacts. The impact on the clinician’s psychological and social welfare can be huge. Completing this volume W. John Livesley offers a thoughtful and comprehensive survey of the available literature on the treatment of personality disorders. With meticulous attention to conceptual detail, he takes the reader along on a search for the essential ingredients of an effective therapeutic approach for these conditions. Livesley sorts out the wheat from the chaff in a realm populated by models as diverse as psychoanalytic therapy, dialectical behavioral therapy, interpersonal therapy, cognitive therapy, transference-based therapy, and so on. He concludes that given modest evidence of differential effectiveness, it seems better to combine therapeutic elements that are common across different modalities and then tailor the interventional gestalt to the problems of individual patients. Livesley’s integrated approach centers upon building and sustaining a collaborative relationship with the patient, maintaining consistency, offering validation of the patient’s intrapsychic experience, and creating motivation and commitment to change. Anchoring his ideas in a convincing dialectic of empirical evidence and conceptual hypotheses, Livesley offers the reader a lesson in tempered optimism and realistic hope in regard to treating severe personality disorders.

xvi

Preface

This brief summary of the book’s contents can hardly do justice to its broad scope and conceptual richness. Its purpose is simply to whet the reader’s intellectual appetite. By offering a distilled overview of the text that is to follow, this summary might also make the reader’s task easier; it is akin to a road map. In addition, recounting the various contributions to the book underscores both the diversity and harmony of its contents. It also is a reminder of the essentially collaborative nature of this academic venture. All four purposes of this summary (whetting the appetite, making learning easier, creating order out of seeming scatter, and valuing collaboration) are the attributes of a good administrator and good educator. Henk-Jan Dalewijk, our esteemed colleague to whom this book is dedicated, is both and we hope that he would find it a fitting tribute to his timeless efforts in the realm of mental health education and his deep concern for those with personality disorder. We would like to express our gratitude to Annette Goozen, Monique Buijs, Roseann Larstone, and Melissa Nevin for their accuracy and patience in organizing and preparing the manuscript of this book. Bert van Luyn Salman Akhtar W. John Livesley

1 1

Treatability in severe personality disorders: how far do the science and art of psychotherapy carry us? Michael H. Stone

Personality disorders, severe and otherwise, constitute what one might call a fuzzy set, after the theory developed by Lotfi Zadeh (1987), and expanded by Bart Kosko (1993). An analogous concept is that of “warmth” as applied to the ambient temperature: there are numbers below which almost no one would consider the temperature “warm,” and other readings, say – above 122 ◦ F/50 ◦ C – that would almost universally be experienced as too warm. As the temperature approached 50 ◦ C, gradually increasing percentages of people would conclude it was “too hot.” This gradual change, which would speed up as one got very near to 50 ◦ C, is the fuzzy set. As Kosko points out, the term life is itself fuzzy (p. 242). When it begins (when the sperm meets the egg? at the blastula stage? later?) is a matter of shading; a matter of degree and debate. Questions concerning fuzzy sets are decided often by expert opinion, not precise scientific measurement. In the domain of medical diagnosis, models that use cluster analysis may begin with performing a clustering algorithm on a set of patients – “by examining (a) the similarity of the presence and (b) the severity of symptom patterns exhibited by each” (Klir and Folger, 1988, p. 252). The authors mention that the similarity measure is usually computed between the symptoms of the patient in question and the symptoms of a patient possessing (by experts’ agreement) the prototypical symptom pattern for each possible disease or condition. The most likely diagnostic candidates “. . . are those disease clusters in which the patient’s degree of membership is the greatest” (p. 252). This line of argument is relevant to the task at hand, inasmuch as personality disorders, to a much greater extent than is the case with more distinctive conditions (such as mania or anorexia), differ widely in severity and at the same time often contain elements that are shared by two or three or more “disorders” that bear different names when conceptualized as categories. At the low end of severity, for example, the personality disorders shade into the normal population, ceasing at some  C Cambridge University Press 2007

1

2

Michael H. Stone

“fuzzy” band on the continuum even to be a disorder. Meantime, ego-centricity – as a personality trait – is shared by the categories of narcissistic personality disorder (NPD) and antisocial personality disorder (ASPD), and reaches its height, i.e., is most severe, in the category of psychopathy, as defined by either Hare et al. (1990) or by Cooke and Michie (2001). Much of the current dissatisfaction with the traditional category approach to diagnosis in the domain of personality disorders as exemplified by the Diagnostic and Statistical Manual of Mental Disorders (DSM, 1994) derives from considerations of this sort. Particularly in discussion of responsiveness to therapy, acknowledgement of the dimensional aspects of personality disorder becomes necessary. But this is simultaneously to acknowledge the fuzziness of the concepts inherent in this domain. It is clear to most investigators and clinicians working with personality disorders, for example, that a patient showing four of the items for borderline personality disorder (BPD) (one short of meeting DSM criteria) may lay better claim to a diagnosis of BPD if those four items happen to be the ones considered most common or most close to prototypical of the disorder, as compared with another candidate patient showing five of the weaker items, or even some other candidate patient with six items – all present, but with only meager intensity. By the same token, psychotherapists with broad experience in treating personality disorders are aware that the difficulties attendant upon working with the most ominous-sounding categories (e.g., paranoid, antisocial, passive-aggressive) may be surprisingly fewer than those associated with the most intense and severe of the supposedly more easily treatable disorders. Put another way, the most avoidant or most dependent persons, every sector of whose lives is permeated by those traits, will prove more challenging (or perhaps untreatable altogether), compared with another person who shows merely a “touch” of paranoid traits confined just to a few relationships in just one sphere of life. It is observations of this sort that bedevil the attempts of any investigator to “well-order” the different categories of personality disorders from the most easily treatable to the most difficult. I have attempted to do so elsewhere (Stone, 2006), but have added the same caveat as mentioned here; namely, that the personality disorders usually placed in the inhibited category (DSM’s Cluster “C”) – which were the main types treated by the psychoanalytic pioneers – can in certain cases prove quite daunting, whereas a narcissistic or schizotypal patient with good reflective function (Bateman and Fonagy, 2004a) and good motivation may prove more easy to treat and more rewarding to work with. That said, the categories of psychopathy and sadistic personality (neither of which even figures in DSM) remain at the low end of any scale of treatability, no matter how one may configure such a scale.

3

Treatability in severe personality disorders

Factors that influence amenability to psychotherapy There are numerous factors that affect the treatability of personality disorders by psychotherapeutic means. The factors are basically the same as relate to the amenability of any condition to psychotherapy – by any of the acceptable therapeutic approaches, granted that some of the factors will figure more importantly in one approach, less importantly in another. Table 1.1 offers both a list of these factors and a guideline for evaluating each one. The list may be viewed as a collection of fuzzy sets, since each attribute or factor can vary over a wide range. Most of these can vary from high to low as in the case of psychological mindedness, mentalization (as defined by Bateman and Fonagy, 2004a), intelligence, empathy, likeability, and the various spirituality qualities. Life circumstances and cultural factors will vary between favorable and unfavorable; object relations, from harmonious to impaired (and within this factor, attachment style may vary from secure to entangled or dismissive); and concomitant symptom disorders such as substance abuse and depression, from absent to serious. Experience with many configurations of personality makes it clear that a good prognosis for psychotherapy does not require optimal levels of all the variables in Table 1.1. Persons with mild antisocial traits, for example, often score poorly on measures of mentalization or “reflective function,” as well as on empathy. I am using the term empathy here to signify both the capacity to read correctly the emotions signaled in another person’s face and compassion. Empathy in this larger sense distinguishes the ordinary person from the psychopath, who, as BaronCohen emphasizes (2003), is often adept at “mind-reading” but lacks compassion. The mildly antisocial person may respond reasonably well to a cognitive-behavioral therapeutic approach of the sort recommended by Beck and Freeman (1990), even though the response to a psychodynamic therapy might be meager. The variables listed in Table 1.1 do not all carry equal weight vis-`a-vis their impact on amenability to psychotherapy. The mildly antisocial person with limited reflective function but good motivation may become “the tortoise that outruns the hare” endowed with excellent reflective function but no motivation. One sees the latter situation in certain schizoid patients. Worse still, the psychopath (meeting the criteria established by Hare et al., 1990) has neither attribute, because, as Hare said elsewhere (1993), “. . . psychopaths are perfectly happy with themselves, and they see no need for treatment, at least in the traditional sense of the term” (p. 203). Motivation thus emerges as a sine qua non of amenability to therapy, since in its absence there is no patient. Two other weak links in the chain that binds patient to therapist during the long work of treatment are candor and character. The opposites of candor are

4

Michael H. Stone

Table 1.1 Guideline for evaluating treatability factors Treatability factors

Evaluation: high, low, etc.

A-1 Ability to think about oneself & others, and about one’s feelings Introspectiveness Psychological mindedness Mentalization Empathy

high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low above avg. . . . avg. . . . . . . . . . . . below avg

Uprightness Likeability

high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low

Hopefulness vs despair Forebearance vs impatience Humility vs false pride Other- vs self-oriented Faith in self vs disillusion Self-acceptance vs self-pity Resignation vs bitterness Serenity vs tormentedness Forgiveness vs grudge-holding Compassion vs hardheartedness Uncomplainingness vs querulousness Self-transcendence vs giving up easily Common decency vs meanspiritedness Dignity vs lacking in dignity Morality vs moral shabbiness

high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low

A-2 Intelligence B Character

C

D E F G H I J

Spirituality

Candor Motivation Perseverance Life circumstances Object relations Cultural factors Symptom disorders

high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low high . . . . . . . . . . . . . . . . . . . . . . . . low favorable. . . . . . . . . . . . . . . . . unfavorable harmonious. . . . . . . . . . . . . . . . impaired favorable. . . . . . . . . . . . . . . . . unfavorable serious moderate mild absent

(For the Spirituality factors, rate as “high,” “average,” or “low” – the positive factors only: e.g., hopefulness, forebearance, humility, etc.)

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Treatability in severe personality disorders

deceitfulness and withholding (“guardedness”). The patient who lies is, in effect, creating a different persona, such that the therapist is reduced to treating merely a “look-alike” of the real patient, whose true nature remains hidden. Deceitfulness, if persistent, creates an insuperable barrier to therapy. The guarded patient (as one sees with many paranoid persons, or with avoidant patients who struggle under inordinate shame) presents difficult resistances that skillful therapy can often resolve eventually, though not always. I think in this regard of a markedly avoidant, depressed, and shame-ridden woman I undertook to treat years ago, whose main problem (as I was to learn by chance only many years later) was her shame about being homosexual. She was never able to reveal this either to me or to the two other therapists she subsequently saw. So in her, guardedness proved a stumbling block that could not be overcome. Regarding character, I am using the word here in its everyday meaning, denoting the set of values and standards by which a person lives, and by which each person becomes known over the course of a lifetime. This is the sense in which Freud was speaking of character when he commented a hundred years ago: “One should look beyond the patient’s illness and form an estimate of his whole personality; those patients who do not possess a reasonable degree of education and a fairly reliable character should be refused” (refused, that is, for psychoanalysis) (1904). Generally, there is a correlation between shabbiness of character and various degrees of narcissism. The spectrum of narcissism may be understood as stretching between “narcissistic personality” as in the DSM, at one pole, passing through malignant narcissism, and on to antisocial personality, and finally, to psychopathy. The malignant narcissist, as Kernberg describes this personality type (1992, p. 77), manifests ego-syntonic sadism, a measure of antisocial behavior, characterologically anchored aggression, and a paranoid orientation, while still retaining a capacity for loyalty and for feeling guilty. Even persons whose array of traits does not quite fill criteria for narcissistic PD, if they show shabby character, they will at least have some distinctly narcissistic qualities: they care more about themselves, after all, than about anyone else. Two brief examples will illustrate this point. One concerns a woman in her mid-20s who suffered a rejection in her first love-affair. Besides her emotional superficiality and depressive core, she was also remarkably immature and self-centered. She set about stalking her ex-boyfriend via hundreds of e-mails and telephone calls to his home and office, sometimes pretending to be someone else scolding him about how terribly he had treated his girlfriend. He finally complained to the police, and she was arrested and spent a night in jail. It was only on the threat of facing a long sentence were she to repeat her behavior that she finally stopped the harassment. Had she owned a gun, she would not have hesitated to kill him, after the manner of many a rejected lover with extreme jealousy and obsessive fixation on the former lover (Buss, 2005, Chapter 1). The other example concerns a narcissistic man

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Michael H. Stone

nearing 40, married, father of a few-months-old daughter. He fancied himself a photographer, but his work was never accepted, and he was unemployed. His wife worked and supported the family, while he stayed home in the (for him) uncomfortable role of house-husband. What brought him to therapy was his anxiety about his receding hairline, making him afraid that he could no longer succeed in picking up young girls at the beach. One day his wife returned home unexpectedly – to fetch an umbrella: she overheard him talking on the phone to some young girl he had met at the beach the week before. Psychotherapy at this point consisted in admonishing him that he had to make a choice between (1) divorce or (2) giving up cheating on his wife (on whom he was economically dependent) and trying to deal in a mature fashion with his marriage and parenthood. Fortunately, he possessed enough character to commit himself to the second alternative. At follow-up 20 years later, he was still married, was working and had made a reasonably good adjustment to the responsibilities of adult life. But where character falls below some critical level, as in the thoroughly antisocial or psychopathic person, even the most carefully designed behavioral therapy, carried out by the most skillful therapist, would promise little improvement. Time and the maturation that comes with age will sometimes accomplish what therapy failed to do, as in some of the cases of chronic alcoholic and moderately antisocial persons described by Donald Black (1999). A` propos, the personality and the skill of the therapist should be included as an important variable affecting the treatability of the severe personality disorders. In the severe cases, one cannot make a neat dividing line between the characteristics of the patient and those of the therapist, since many patients in this category will fail to improve with a fair number of therapists, yet may show remarkable improvement when working with a therapist of special skill and where the two personalities “click.” Judd and McGlashan (2003), in their outstanding book on borderline personality, mention, for example, that “Work with BPD patients is not for everyone. . . . Flexibility and creativity within an ethical and commonsense frame of reference not only are essential but make the work challenging and rewarding” (p. 173). They go on to caution that “Work with BPD patients requires a better than average ability to maintain consistent empathy” (p. 186), adding that “Treating BPD patients requires a therapist who can tolerate anger, neither personalizing it, nor becoming so anxious that he is intimidated . . . into premature responses and actions” (p. 202). This need for the proper “click” between therapist and patient is particularly evident in the treatment of borderline patients, in contrast to the situation with neurotic-level, better integrated persons who enter psychoanalysis. As an example of the latter situation, it was the custom at the Columbia Pyschoanalytic Institute years ago that the match between the training analysts and the beginning candidates was made by having the training analysts pick the names of their prospective candidates

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Treatability in severe personality disorders

out of a fishbowl. There were rarely any problems. It was assumed that the trainees could work out whatever problems they had either in their interpersonal lives or in the choice of which analyst they ended up with via analysis with any of the training analysts. The trainees usually showed no more than mild obsessive-compulsive or depressive-masochistic traits that were generally “subclinical” with respect to the criteria in DSM. If some of the candidates were initially unhappy with the choice of analyst assigned them, this disappointment was merely a problem to resolve in the beginning phases of the therapy: one that probably highlighted similar problems in the everyday lives of the trainees. Borderline patients behave quite differently. Many embark on what seems like an extended odyssey past half a dozen or more therapists, till the “right” one is at last discovered. Since this process depends on the subtle “chemistry” between the two participants, it is difficult at the outset to predict which therapist will be the “right” one for a given borderline patient. The following vignette is illustrative: A woman of 20 was referred to a psychiatric hospital in New York that specialized in the long-term psychodynamic treatment of borderline disorders. She had been placed in special boarding schools for disturbed children when she was 15. At 18, because she had made a series of nearly lethal suicide attempts, she was sent to a hospital, where she remained for 2 years. Attractive, bright, but nearly mute, she was diagnosed as “schizophrenic” and treated with nearly 100 electro-shocks, which were completely without effect, except to induce a kind of retrograde amnesia, making it harder for her to recall details from her past. She was then sent to the hospital in New York as a “hopeless case.” During the first year-and-a-half of the three she spent on the new unit, she was assigned to two different therapists, but did not feel comfortable with either. She remained nearly mute, confining her thoughts to a diary where she recorded her feelings of despair, unworthiness, guilt, and suicidality. With the third therapist, however, she “clicked” from the very beginning. She began to open up, gradually became less preoccupied with suicide as her “only option,” and was well enough after a yearand-a-half to be discharged. Continuing to work with the same therapist for another 10 years, she first enrolled in college, where she graduated with high honors, and then went to graduate school, earning a PhD in psychology. Meantime she married and began raising two children. In 2005, 40 years after leaving the borderline unit, she is now a practicing psychologist, living in comfortable circumstances with her husband and two grown children, and writing a book about her extraordinary experiences as a recovered patient. She can now speak candidly about the sexual molestation she experienced at the hands of her father and grandfather – which she did not even recall till several years after leaving the second hospital.

Two qualities among the many that contributed to her eventual recovery were: she was not schizophrenic by any acceptable criteria, and, in line with the favorable items in Table 1.1, she showed no bitterness. Bitterness, as I have argued elsewhere

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Michael H. Stone

(Stone, 2006), appears to exert a rate-limiting effect upon the possibility of recovery in borderline patients, inasmuch as several other such patients, who suffered much less traumata in their early years than did the patient just described, remained embittered persons over the course of their lives, and have made much less substantial gains, especially in the spheres of friendship and intimacy. Estimates of treatability At this point there is little methodical, let alone rigorous, research devoted to estimating the amenability of the severe personality disorder to the various forms of psychotherapy. This is particularly true of the more ordinary disorders most psychotherapists confront in their practice. Forensic psychiatrists working with psychopathic persons in hospitals or prisons utilize a number of measures to estimate recidivism, such as the Violence Risk Appraisal Guide (VRAG), developed by Quinsey et al. (1998) or the Psychopathy Checklist-Revised (PCL-R) of Hare et al. (1990). With regard to the PCL-R, it has been documented that the higher the score on this measure, the higher the rate of recidivism, and, in general, the earlier the recidivism (for either violent or non-violent convictions) following release from an institution (Hemphill et al., 1998). But observations such as these are not so much measures of treatability as measures of untreatability. Comparable data are not available for assessing the responsiveness to therapy of dependent, or paranoid, or compulsive personalities as encountered in everyday clinical practice. There is instead, a kind of attitudinal consensus built up from the collective experience of seasoned psychotherapists, representing different approaches as to which kinds of personality-disordered patients are likely to do well, and which are not. These impressions can be summarized in a way that yields fuzzy sets – approximations, if you will – of the responsiveness to psychotherapy among the various personality disorders. As an example, Figure 1.1 shows the contrasting impressions concerning the amenability of two disorders – dependent and paranoid – to psychotherapy. Paranoid PD is generally considered less responsive than dependent PD, as reflected in the different curves: the curve for paranoid PD is slanted to the left, since there will be a surplus of cases responding at the levels “nil//poor//fair” compared with those responding at levels “good//excellent//optimal.” The curve for dependent PD is slanted in the other direction, since most cases are amenable to therapy, despite a few being so intractable as to show “nil” response. Clinicians, of course, take in a multitude of factors when making their estimations of treatability: not only the ones outlined in Table 1.1, but also such factors as age, work history, and the intensity of traits belonging to other categories of personality. A paranoid personality admixed with antisocial features would represent a more challenging picture therapeutically than a paranoid personality free of antisocial traits. An avoidant person with paranoid features would probably be more difficult

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Treatability in severe personality disorders

Dependent PD

pt im al O

Ex ce lle nt

oo d G

Fa ir

Po or

il

Paranoid PD

N

Percent showing this level

Level of treatability by psychotherapy 40 35 30 25 20 15 10 5 0

Levels from nil to excellent

Figure 1.1

Contrasting levels of amenability to psychotherapy: dependent vs paranoid PD’s

to treat than an avoidant person with dependent features. The sheer multiplicity of combinations renders the task of accumulating statistically useful numbers of all these subtypes quite forbidding, leaving us back where we began, with more expert opinion than hard data. Follow-up data might offer a rough index of treatability, on the supposition that good outcomes in the severe personality disorders might be a reflection of good amenability to psychotherapy, and that, mutatis mutandis, those with poor outcomes owed their eventual fate to a poorer responsiveness to therapy at the outset. The index would be only rough – because we know from the long-term follow-up studies of the 1980s that about one patient in eight behaved counter-intuitively, in the sense that the functional level at long-term was either much better, or occasionally much worse, than the therapists (or treatment staff in hospitals) estimated in the beginning (Stone, 1990a). Furthermore, a proportion of borderline patients treated originally at the Menninger Clinic with expressive (psychoanalytically oriented) therapy were shown to have improved years later under the aegis of expressive therapy, while a proportion of other borderline patients showed similar (but unanticipated) levels of improvement once their therapy had eventually changed to a more supportive mode (Wallerstein, 1986). In the 10- to 25-year follow-up studies (which concentrated on borderline patients, but also included narcissistic and schizotypal patients) good reflective function and high motivation were not guarantors of success: some borderline patients with these characteristics nevertheless committed suicide (McGlashan, 1986a, 1986b; Plakun et al., 1985). Others who abused substances and had few of the favorable factors outlined in Table 1.1 nonetheless made impressive gains years later, little of which could be ascribed to individual psychotherapy (McGlashan, 1986a; Stone, 1990a). These caveats aside,

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Michael H. Stone

Long-term outcome in borderlines Percentage of patients in each category

60 50 40

BPD males BPD females

30

Dysthymics

20

Other BPOrg

10 0

Traced patients suicide incap

marg

fair

good

recov

BPD male: 52 BPD female: 141

Outcome levels (suicide to recovered)

Dysthymics: 34 Other BPOrg: 48

Figure 1.2a Ten- to twenty-five-year outcome in borderline patients in the P.I.-500, by percentages in each level

Number of patients per outcome category

Long-term outcome in borderlines

60 50 BPD Males

40

BPD Females

30

Dysthymics

20

Other BPOrg

10 0 Outcome level (suicide to recovered)

Figure 1.2b Ten- to twenty-five-year outcome in borderline patients in the P.I.-500, by the numbers traced

it is still possible to map out some correlations, based on long-term results, that relate to treatability. If, for example, one looks at the distribution of outcomes (ranging from suicide/incapacitated/marginal to fair/good/recovered) in the nearly 300 patients with borderline personality organization (Kernberg, 1967) from the P. I.-500 study, it emerges that male BPD patients had the highest suicide rate (14%) and the least likelihood to function at the good [corresponding to Global Assessment Score (GAS) of 61 to 70] or recovered (GAS > 70) level when traced (Figure 1.2b).

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Treatability in severe personality disorders

The patients with borderline organization but who did not meet DSM criteria for BPD showed the lowest suicide rate (0%) and the highest rate of recovered-level outcomes. This group is composed mostly of dependent-depressed and depressivemasochistic patients functioning at the borderline level: patients we would now call dysthymic. The results for the BPD females and the borderline-organization patients who were not dysthymic were intermediate between those of the BPD males and the dysthymics. The patients of the “Other BP-Organization” group usually had other severe personality disorders: schizotypal, antisocial, or narcissistic. What are the implications of these data for the issue of treatability? Male BPD patients tend to have stronger admixtures of antisocial traits than do their female counterparts. This probably accounts in part for their worse overall performance. The male BPD patients with concomitant major depression had higher rates of suicide than the females with major depression, even though they may have demonstrated good treatability (as predicted by their good reflective function and good motivation, for example) when first evaluated. But the males with antisocial features usually show poor reflective function and poor motivation – associated with lesser degrees of responsiveness to psychotherapy. The dysthymic patients were the opposite: they usually showed excellent reflective function and high motivation. Depressed persons tend to be intropunitive and introspective, guilt-ridden, and eager to get help, so they would be expected to be good candidates for psychotherapy, and this is customarily the case. The foregoing remarks will serve as a prelude to the next broad topic: that of the follow-up studies of the severe personality disorders, with emphasis on contemporary research. Follow-up studies in the domain of the severe personality disorders In an earlier communication I reviewed the long-term follow-up of personality disorders (Stone, 1993). The data derived chiefly from studies with a retrospective design. Although several of these studies (McGlashan, 1986a, 1986b; Stone, 1990a, 1990b; Stone et al., 1987) had the advantage of large N values and high trace rates (> 85%), they had the disadvantage of retrospective design, where one must of course rely strongly on the memories of clinicians and former patients. These earlier reports concentrated on borderline and antisocial PDs, since the bulk of the relevant information in the literature dealt with these two disorders. Material on schizotypal, schizoid, and obsessive-compulsive disorders was more scanty; little material was available at all on the other PDs, especially on those of the “inhibited” (DSM’s Cluster-C) type (Stone, 1993). This lopsidedness of distribution has not changed appreciably in the intervening years. Follow-up material on borderline and antisocial PDs continues to dominate the relevant literature, as will be evident in the following survey.

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Borderline personality disorder (BPD)

A number of authors have commented on the relative instability of the BPD diagnosis, insofar as a proportion of patients diagnosed “BPD” when first evaluated failed to meet DSM criteria several years later. Links et al. (1998), for example, noted that at 7-year prospective-design follow-up 30 of 57 patients (52.6%) were found to have remitted (in the sense of no longer showing at least five DSM items). The patients who still met BPD criteria at 7 years had significantly more comorbid personality pathology when first seen. Skodol et al. (2005) were interested in determining what was “stable” about various personality disorders (including BPD), given that diagnostic instability is common from the standpoint of category-based diagnosis, even at relatively short (2- to 5-year) intervals. Their impression was that impairment in functioning, especially social functioning, emerged as an enduring component of personality disorder. These findings were similar to those of Ha et al. (2004) in a South Korean study: these authors noted that the BPD patients showed fewer changes in character-related maturity as they got older, compared with those in a healthy control group. The borderline group scored lower, for example, on selfdirectedness and cooperativeness – qualities described by Cloninger et al. (1993) – at the end of the 3-year follow-up period. Some of the findings of the above-cited studies appear at first flush to fly in the face of accepted wisdom: personality is ordinarily a stable quality of people, especially throughout adulthood. One should recall, however, that BPD as depicted in DSM is based more on symptoms and mental qualities that are subject to modification over time, as compared with genuine personality traits. Therapy and medication have a better chance of correcting both abnormalities of mood and tendencies to self-destructive behavior (these are hallmarks of the DSM diagnosis of BPD), and ultimately of firming up instability of identity, than of correcting true traits, such as seductiveness, mercuriality, manipulativeness, childishness, and readiness to anger – all of which figure importantly in the trait-configuration of many BPD patients. Certain of the more enduring traits were associated with poor prognosis in BPD, as noted in the review of Rothenhausler and Kapfhammer (1999): these included most prominently chronic hostility and antisocial tendencies. As to the tendency of treated BPD patients to lose their “borderline-ness” over time, Paris and Zweig-Frank (2001) reported that at an average of 27 years postdischarge from hospital, few of their original BPD patients could still be so diagnosed (5 of the 64 who could still be traced, in a sequel to the authors’ earlier 15-year follow-up). The suicide rate remained a cautionary figure in an otherwise optimistic picture, now having reached 10.3%. Thanks to the heterogeneity of causative factors in BPD and to the variations in different BPD samples, there is not good agreement about some of the factors said to influence long-term outcome. Zweig-Frank and Paris found that parenting quality and childhood abuse or trauma did not have a

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Treatability in severe personality disorders

relationship to outcome (2002), whereas in the P. I.-500 study, parental cruelty and early sexual abuse (especially father–daughter incest) were strongly associated with poor prognosis (Stone, 1990a). In a 3-year prospective study, based on 37 female BPD patients, significant improvements were noted at the end of the 3 years, most patients showing a course of erratic improvement (only a few showing decline over time), with the general finding that the group moved from a “poor” to a “fair” level of overall function (Najavits and Gunderson, 1995). The intermediate size of the sample (N = 37), however, makes generalization difficult. Senol et al. (1997), in a somewhat larger study, reported on their 2- to 4-year follow-up of borderline clinic patients in Ankara, Turkey (1997). Of their original 75 patients, 61 patients could be traced, and 2 had committed suicide. The average GAS score had improved on average over 13 points; concomitant affective disorders were noted in three-quarters of their patients. In general, their data were similar to those of the follow-up studies in the West. The rapidity with which certain self-destructive behaviors (“parasuicidal acts”) can be minimized with good psychotherapy has been noted in several studies, beginning with that of Linehan et al. (1993), who showed the efficacy of Dialectical Behavior Therapy in reducing, within a year’s time, the tendency to self-cutting and other parasuicidal behaviors. A similar reduction in such behaviors was also achieved within a similar time period, using Transference-Focused Psychotherapy (TFP), a psychoanalytically oriented form of therapy developed by Otto Kernberg and his colleagues (Clarkin et al., 2001). In a prospective study at the McLean Hospital in Boston, Zanarini and her colleagues (Zanarini et al., 2003) evaluated 362 inpatients with a personality disorder: 290 of these met criteria for BPD. These patients received a variety of treatments before and during their hospitalization, so the study focused more on the natural course of treated BPD than on the effects of one particular type of therapy. At all events, 202 of the BPD patients remitted by 6 years (i.e., they no longer met full DSM criteria), whereas the remaining 88 could still be diagnosed as borderline. In the more favorable subgroup, comorbidity for other PDs also declined, though in the still-BPD patients, rates of the inhibited anxious-cluster subtypes (dependent, avoidant, and self-defeating) remained high (Zanarini et al., 2004). The authors suggested that the anxious cluster disorders were the personality disorders that most impeded symptomatic remission in their borderline patients. This may be a reflection of a paucity of concomitantly antisocial traits in their sample, given that the combination of BPD and ASPD is generally associated with poor prognosis (Stone, 1990a). The no-longer-borderline patients were more likely, at 6-year follow-up, to have formed a good relationship with a sexual partner and to have sustained good performance at work (Zanarini et al., 2005).

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Michael H. Stone

Where there is an admixture of narcissistic traits, enough to warrant a diagnosis (in category terms) of BPD × NPD, long-term outcome is similar to that of BPD in general, unless there was a further admixture of antisocial traits (Stone, 1990a). In the latter situation, amenability to psychotherapy was poor. In males with BPD × NPD, even in the absence of antisocial traits, there was a heightened risk for suicide. Some of the patients in that group showed good reflective function and motivation for therapy, but were brittle, apt to succumb to certain life stresses, precipitously and in ways that were hard to predict, and to commit suicide via violent means (e.g., hanging, jumping from high buildings). As for the suicide risk in BPD, there appears to be no correlation between the high suicide rate (which varies between 3% and 10%, according to the sample and length of follow-up) and amenability to psychotherapy. Patients with BPD who engage repetitively in manipulative suicide gestures often turn out to be engaged in a kind of high-stakes gambling within the interpersonal arena. Emotional blackmail of this sort is employed, for example, in the service of shaming a departed lover back into the uncomfortable relationship from which he or she had just fled, or in securing some other desired goal through this heavy-handed means. Ironically, the borderline patients who come to rely on this technique are often of a hostile, demanding, and externalizing bent, with only a fair to poor level of psychological mindedness and reflective function. The risk for completed suicide or even for high-lethality attempts is often less in this group than in borderline patients who suffer from severe, recurrent depression. In the latter group, the key clinical feature is genuine despair (along with profound hopelessness about the future), rather than manipulation. Yet borderline patients with serious depression and despair often show excellent degrees of reflective capacity and introspectiveness, such that they work well in psychotherapy. Some ultimately improve greatly and overcome their suicidality, while a few others impulsively kill themselves when confronted with a sudden life stress that they regard as insuperable. The impact of certain types of life events was noticeable across the personalitydisorder axis, not limited to BPD, as observed by Yen et al. (2005). In their study, negative life events, especially those related to love relationships or to legal/criminal matters, were significant predictors of suicide attempts during the 3-year follow-up interval of the study. A history of childhood sexual abuse (to which female children are substantially more vulnerable) was identified as a strong predictor of future parasuicide behaviors, more so than the diagnosis of BPD itself (Soderberg et al., 2004). There will often be an interaction between the negative events and patterns in childhood and subsequent adverse life events of adult life, the one predisposing to the other, as the following vignette shows.

15

Treatability in severe personality disorders A woman of 22 had been adopted at age 6 months into a family where the mother was rejecting and punitive. There was a history of serious depression and eating disorder in the biological mother and her family. The woman was sexually abused during her adolescence by a former lover of the mother, following which she experienced a series of major depressive episodes, accompanied by feelings of hopelessness and by suicide gestures. Greatly talented artistically, the woman won scholarships to a variety of prestigious universities, but her mother refused to permit her to attend these centers, urging her instead to pursue a more “practical” course of study in an area of no interest to her daughter. Psychologically astute and insightful, she entered psychotherapy and made impressive gains for a time. She moved to a different city, became embroiled in two disastrous love affairs with abusive men (the male replicas of the hostile mother– daughter relationship) before finally meeting a more suitable young man. But she felt unworthy of his love, and ended the relationship – via suicide gestures that signaled to him her instability. She received some financial support from her family, so long as she pursued studies of which they approved, but she was unable to complete her college courses. She became seriously depressed once again, at which point her parents insisted she return home. They cut off her financial support, and a few days later she took a fatal overdose of acetaminophen.

In any event, suicidal behaviors are a force to be reckoned with in BPD, whether these are of the manipulative, or the serious, more lethal sort. Mehlum et al. (1994) noted, in their study of 97 patients admitted to a day-unit (41 BPD, 33 other PD’s, 23 no PD), that the BPD patients more often had a lifetime history of suicide attempts, and continued to be more suicide-prone 2–5 years later. But there was a subgroup of BPD patients without suicidal behavior, and they did nearly as well as the non-BPD patients. Only two in five still met DSM criteria for BPD at follow-up. Before addressing the issue of treatability in greater detail further on, the two examples given here – of the incest victim who has done remarkably well, and of the rejected adoptee who committed suicide – highlight the difficulties inherent in generalizing about the connection within the borderline domain between the treatability factors listed in Table 1.1 and long-term prognosis. Good treatability factors do not always predict good long-term outcome, and some BPD patients who seemed most unpromising when first evaluated ultimately do better than anyone expected. The better-than-expected outcomes seem related more to the patients’ perseverance than to their psychological mindedness and responsiveness to conventional therapies. Schizotypal personality

Within the schizophrenia spectrum, schizotypal personality disorder (STPD) is considered more closely related to the parent concept of schizophrenia than are the

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Michael H. Stone

other two Cluster-A types: schizoid and paranoid. As I have indicated elsewhere, psychotherapy with the Cluster-A types tends to be a lengthy process, sometimes a lifelong project, owing to the difficulties that patients with these disorders manifest in reading correctly the social field. This tendency to misinterpretation is especially marked with paranoid patients, but is a major problem with schizotypal patients also (Stone, 1996). Earlier, I commented on the amenability of STPD patients to “analytically oriented psychotherapy” (Stone, 1985), mentioning likeableness, autoplastic defenses (akin to introspectiveness, as opposed to the externalizing defenses shown by paranoid persons), and self-discipline as positive factors; vengefulness and a history of parental abusiveness proved to be negative factors. McGlashan (1986b) noted that STPD was rare as a pure syndrome; when admixed with BPD comorbidity its outcome was closer to that of BPD than to that of schizophrenia. In the P. I.-500 study, the STPD patients were to be found, on average, in the “fair” (GAS 51–60) range at long-term outcome, doing less well than the BPD patients, albeit with a negligible suicide rate. In the prospective follow-up study of four types of personality disorders, Grilo et al. (2004) found that depending on the stringency of criteria for improvement 38% to 61% of STPD patients had “remitted” after 2 years (vis-`a-vis DSM category diagnosis). The authors concluded that personality disorders were characterized by trait-constellations that were stable over time, yet capable of change in severity or expression. One might see, for example, a patient improve to the point where STPD diminished in intensity to a condition no longer meeting DSM criteria, and now better regarded as “schizotypal traits.” Many psychiatrists report having one particular patient whom they have kept on in therapy from their first days in practice. Such patients are likely to be schizotypal: they are not good at small-talk, are maddeningly concrete in their use of language, lack the empathic skills to fit in well in the social arena, and end up leading marginal lives. They are the most eccentric of the Eccentric-Cluster patients. But they may compensate for these deficits with remarkable perseverance and motivation, such that they remain in treatment year after year. Thorkil Vanggaard (1979) described his experience with such a patient. There is a schizotypal patient with whom I have worked since my second year in practice 39 years ago. The therapeutic approach will usually be supportive with STPD patients. Those who are relatively free of paranoid admixture tend to improve to a greater degree than those with marked paranoid features. A brief example may illustrate this point. My “life” patient has moderately strong paranoid features, and was once at the point of accusing her boyfriend of having “stolen one of her gloves,” when she noticed one evening that she couldn’t find one of a certain pair. I bet her ten dollars she would find that glove the next day under some piece of furniture, but that, in any case, she had better not accuse her friend of “stealing” one glove (a totally useless theft), lest he think her quite mad and break off the relationship. She kept quiet about it, and sure

17

Treatability in severe personality disorders enough found the missing glove the next day under the sofa. My intervention kept her on the right social track, which she was about to swerve off (this is the root meaning of ec + centric), thus safeguarding the relationship.

Schizotypal patients often show many of the favorable treatability factors, and do improve, but do so very slowly. Parnas et al. (2005) mention the oft-repeated observation that patients with Cluster-A disorders do not seek treatment for the traits that define these disorders, but rather for depression or anxiety. This complicates the task of assessing any improvement after a course of therapy, since improvement may stem from alleviation of the distressing symptoms rather than from rectification of the maladaptive traits. Antisocial and psychopathic personalities

Persons who exemplify the features of ASPD, psychopathy, and, even more so, sadistic personality are the least likely to show the favorable factors sketched in Table 1.1. Such persons customarily lack even the capacity for loyalty that demarcates the malignant narcissists (Kernberg, 1992), where amenability to psychotherapy is already problematical, from their still less treatable antisocial and psychopathic counterparts. Mildly antisocial persons, especially those who are non-violent and who skirt the edges of the law either without getting arrested or with a few arrests for minor offenses, have shown improvement at the hands of skilled cognitivebehavioral therapists, via techniques described by Beck and Freeman (1990, pp. 147–175) or by Black (1999). The value of time, and the maturation that may come with it, I underlined in a discussion of a Swedish man (Stone, 2006, Chapter 9) who was rebellious, drug-addicted, and larcenous from adolescence till his late 40s. At that age, while in jail, he thought about the way he was wasting his life, and determined from then on to stop using drugs and to seek psychotherapy (which hitherto he had pooh-poohed as worthless). Now in his early 50s, he has straightened out, to become a counselor at a clinic for men with problems similar to the ones he at last conquered. He also began to feel genuine remorse for the time when, as a “bully” at age 9, he and another boy got angry at a teacher they disliked, and dropped her out of a third-storey window: she survived, but died many years later before he ever got a chance to tell her he was sorry. This capacity for remorse marks him as much more “workable” as a patient in therapy, than would be the case with a psychopath. In psychopathy, situated at the outermost edge of the narcissistic spectrum, the “human” qualities of remorse, compassion, genuine concern for others, responsibility-taking and a sense of fairness are all lacking, as is any respect for the profession of psychiatry. Treatability falls to zero. Contemporary research has sought to understand the differences between those antisocial persons who are habitually aggressive and those who are not. Eley et al. (2003), in this

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regard, draw attention to two subgroups, which they call the aggressive versus the non-aggressive. In their study based on more than 1000 twin pairs, the aggressive form, which the authors found to have high stability over time, showed high heritability, as they had anticipated. The non-aggressive form was influenced by genes and the environment, and showed less genetic stability over time. Their study did not focus on treatability, though it may turn out that the aggressive subtype proves less amenable even to behavioral therapy. Their violent propensities are more likely to lead to incarcerations, where exposure to hardened criminals is likely, leading to a hardening of the personalities of the new and younger inmates. The life-course of Charles Manson is illustrative in this connection (Emmons, 1986): incarcerated as a teenager for minor crimes, he was beaten and sodomized by the bigger men in prison, which left him more misanthropic and vengeful when released than he was when he entered. In a related study, persons designated as “early starters” in their careers as offenders scored lower on scales of responsibility and socialization (and higher on the Minnesota Multiphasic Personality Inventory (MMPI) scales of paranoia, schizophrenia, and hypomania) than did those offenders who began in late adolescence/adult life to commit crimes (Ge et al., 2003). The early starters have more of the characteristics of the psychopath, and may carry more genetic risk for low empathy (Baron-Cohen, 2003), rendering them more contemptuous of ordinary social standards and more willing to break social rules. As to the efficacy of therapy in forensic settings, Greeven and de Ruiter (2004) assessed 54 male and 5 female patients in a forensic hospital, comparing their initial evaluations with those made after 2 years of treatment. They found that 40% had shown significant reductions in personality-disorder pathology (as measured by the personality diagnostic questionnaire – revised, PDQ-R); about 25% improved to a clinically significant extent, displaying fewer personality-disorder features. The authors could not as yet be sure whether these changes equated with a substantial reorganization of personality, or merely with changes at a superficial level. Extended follow-up after release from hospital would be necessary to clarify these points. The effects of childhood antisocial personality (evident before age 15) on the nature and course of BPD were studied by Goodman et al. (1999) in their evaluation of 107 female inpatients with BPD. Three prediction factors were detected in relation to childhood antisocial personality: rule-breaking, assault, and sadism. Early rule-breaking, for example, predicted unstable relationships and heightened severity of the BPD picture. The increase in severity of BPD, given early antisocial tendencies, argues for added difficulties in the treatment of such BPD patients; i.e., for diminished amenability to psychotherapy. Whereas the above-cited studies concentrated on the broader concept of ASPD, several others focused on the narrower concept of psychopathy – which may be understood as a smaller domain within the larger realm of antisocial personality.

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In their 10-year follow-up of 157 boys aged 12 through 18, Gretton et al. (2004) using the Youth Version of the Hare Psychopathy Checklist (PCL:YV) found that the risk for violence continuing into adulthood was greater among those with high PCL:YV scores, compared to those with low scores. These studies focused more on the natural history of antisocial and psychopathic persons than on their response to psychotherapy, apart from that of Greeven and de Ruiter, but even theirs concerned forensic patients, not a prison population. As a rule, offenders meeting full criteria for psychopathy (PCL-R scores ≥ 30 in the US and Canada; ≥ 25 in Europe) are more likely to be found in the prison than in the forensic-hospital setting. There is a general impression that persons with ASPD are at best difficult to treat; many seem beyond the reach of available treatment approaches, although a fair percentage “burn out” (cease to indulge in antisocial acts) as they reach or get past the age of 40. This burn-out may occur in a third of persons with ASPD (Cloninger, 2005, p. 163). In his comprehensive and thoughtful review of ASPD, Cloninger (2005) emphasizes that the picture vis-`a-vis treatability is not “hopeless” as many clinicians and investigators have assumed. He cites Lipsey and Wilson’s meta-analysis (1993) of many studies, from which one could conclude that “. . . structured behavioral treatments in which there is no cooperative therapeutic alliance have a small but positive effect size according to multiple randomized controlled trials” (p. 163); where there is such a positive alliance, the effect size rises to moderate levels. Cloninger cautions that therapeutic nihilism about the treatment of ASPD is invalid, but apt to lead to a self-fulfilling prophecy. The latter situation could come about because therapists, convinced that their ASPD patients are anyway untreatable, devote less time, effort, or ingenuity to the task. One must keep in mind, however, that in many studies of ASPD treatment, smaller or greater numbers of psychopaths may be conflated with the antisocial patients who do not meet full criteria for psychopathy. In forensic hospitals one may also see patients (among them, those who have murdered) who are neither antisocial nor psychopathic, but whose personality disorder (e.g., schizoid, obsessive-compulsive, paranoid) is of such severity, and who are so resistive to the very notion of psychotherapy, that they show no improvement over the years. Patients of this sort often get misdiagnosed “antisocial” as a reflection of the anger and impatience of the treating staff. These patients then contribute inadvertently to the gloomy prognosis that inheres to the concept of ASPD. The point to remember is that some ASPD patients are untreatable, but not all. And some untreatable offenders, albeit diagnosed “antisocial,” have not been correctly diagnosed. The poorest prognosis for treatability will be found in persons who show the fullblown picture of psychopathy. Diagnostically, they may meet criteria for ASPD and psychopathy, or for psychopathy alone (Stone, 1994). Persons – and they will usually be offenders – who in addition manifest strong sadistic features have a vanishingly

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lower amenability to psychotherapy and a still worse prognosis for social recovery (Stone, 2006). There are a number of complexities to consider in evaluating the treatability of psychopathy. The PCL-R scale of Hare is weighted more heavily on criminological items (engaging in a multiplicity of different crimes, called “criminal versatility,” revocation of conditional release, juvenile delinquency) than is the Cooke scale. But certain offenders from affluent families are better at avoiding arrests, let alone convictions, until they commit an extremely serious violent offense; they often had not been delinquent in adolescence, such that they fly underneath the radar, so to say, with respect to the criteria for full-blown psychopathy. What these offenders are likely to show is the full set of Hare’s Factor-I traits; that is, the extreme narcissistic traits of glibness, grandiosity, deceitfulness, conning/manipulation, callousness, lack of remorse, lack of empathy, and failure to accept responsibility for one’s actions. These are by far the most worrisome subset of traits subsumed under the heading of psychopathy, when compared with the behavioral items of Factor-II. Yet someone scoring a “2” (on Hare’s 0-1-2 scoring system) predominantly on the narcissistic items will end up with a score in the 15 to 20 range (“moderate” psychopathic traits), and seem more promising vis-`a-vis treatability and outcome than another person exhibiting some of the narcissistic traits but many of the Factor-II items, who might actually be more reachable by behavioral therapy, 12-step programs, and the like than the pure narcissist. This brings us to the question posed by Gacono (2005): is psychopathy a taxon or a dimensional construct? As Gacono rightly asserts: “This is a trick question. Psychopathy is both a categorical designation (i.e., a taxon; PCL ≥ 30) and a dimensional construct, dependent on its application” (p. 171). He adds that dimensional uses are recommended for clinical applications, where psychopathy can be graded on a spectrum of severity, in hopes that there is a useful correlation between the scoring and the prediction of violent or other recidivism. Even here, as mentioned just above, socioeconomic class and other considerations may cloud the issue, with the result that some individuals scoring in the intermediate range, dimensionally, may nonetheless be more dangerous and more resistant to any form of therapy than some of their higher-scoring counterparts. The assessment of treatability in psychopathy is further complicated owing to the appearance in recent years of several articles suggesting that incarcerated offenders meeting criteria for psychopathy proper (PCL-R ≥ 30) tend to do worse when treated, than those who were not treated (Rice et al., 1992; Seto and Barbaree, 1999). The conclusion to which one was led was that the psychopath figured out what to say and what not to say, thanks to what he learned in the various group and other therapeutic sessions in the institution, thus improving his ability to “con” the staff into granting release, whereupon the psychopath quickly resumes his old habits and re-offends. As D’Silva et al. commented (2004), this creates a

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paradoxical situation in which psychopaths are told they cannot be considered for release if they do not participate in various treatment programs, yet are considered inappropriate for such programs, lest they misuse what they are taught – in the service of manipulating the staff to grant them a release they do not really merit. As is also mentioned in Chapter 11 by Reid Meloy and James Reavis: D’Silva points to certain flaws in the previous studies, particularly that psychopaths who were treated were not compared with psychopaths who were not treated, but instead only with lower-scoring offenders with some psychopathic traits (who fell short, that is, of psychopathy qua taxon). She and her colleagues make a good case that it is premature to conclude pessimistically that treated psychopaths are more apt to offend than their untreated counterparts. They urge that new studies with a scientifically more compelling research design be implemented, so as to better answer the question concerning the efficacy, or even the advisability, of treatment. That said, there remains a group of persons at the outermost extreme at the negative end of the bell-curve of treatability, where amenability to any form of currently available therapy hovers near to, or rests at, the zero point. I refer to psychopaths whose scores on the narcissistic traits are maximal, and who in addition are chronically violent and sadistic. Nearly all men committing serial sexual homicide (Stone, 2001) fall into this end-region. Almost half also manifest marked schizoid personality traits. This, coupled with their lack of empathy (accompanied often enough with an utter contempt for the feelings and rights of others), leaves them essentially impregnable to the effects of any therapeutic regime. The indifference to the feelings of others shown by the sadistic psychopath has been captured graphically by the articulate serial killer Michael DeBardeleben. As quoted by Hazelwood and Michaud (2001) in their book on sexual sadism, DeBardeleben wrote of sadism in this way: Sadism as the wish to inflict pain on others is not the essence of sadism. The central impulse is to have complete mastery over another person, to make him or her a helpless object of our will. . . . And the most radical aim is to make her suffer. Since there is no greater power over another person than that of inflicting pain on her. To force her to undergo suffering without her being able to defend herself. The pleasure in the complete domination over another person is the very essence of the sadistic drive. (p. 88)

The full story of DeBardeleben’s cruelty can be gleaned from his biography (Michaud, 1994), the details of which should serve as a compelling demonstration of his imperviousness to treatment. Cloninger’s essay on ASPD offers us a more balanced view about the treatability and prognosis of antisocial persons than the severely pessimistic view that has come to permeate the literature. Likewise, D’Silva’s words of caution are well taken – concerning the hitherto even more pessimistic view about the treatability of the (high-PCL) psychopath. But untreatable persons

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do exist. And to become convinced, one needs to get down to cases. This is what the full-length biographies of notorious criminals provide (especially, those who have murdered or tortured repeatedly): a glimpse into the realm of the untreatable. Concluding remarks on the efficacy of treatment Thanks to the number of recent studies of outcome in patients treated for severe personality disorders by a variety of methods, we now have reports on the efficacy of psychodynamic, self-psychological, cognitive-behavioral, and supportive approaches to most of the Axis-II disorders. The meta-analysis carried out by Leichsenring and Leibing in G¨ottingen (2003) focused on psychodynamic and cognitive-behavioral therapies, 22 studies in all, either naturalistic (11) or randomized (11) in design. The authors concluded that both dynamic and cognitive-behavioral therapies achieved good effect sizes. The favorable effect sizes in the psychodynamic studies indicated long-term gains; those in the cognitive-behavioral studies were more indicative of short-term changes. Half of the studies concentrated on borderline patients, and most of the reports cited were based on outpatients. The one study devoted to antisocial patients dealt with depressed versus non-depressed opiate addicts with ASPD, and thus represents a very different patient population than the antisocial and psychopathic offenders surveyed in the forensic literature. The real problem for clinicians reviewing this literature comes in trying to apply the data to their own particular personality-disordered patients. Besides all the variables in Table 1.1 there are the additional variables related to gender, age, history of hospitalizations, and, if there were hospitalizations, whether they were single or multiple, brief or protracted, and occasioned by serious suicide attempts or by milder precipitants. Of equal importance, what is the patient’s main personality configuration, and what are the next most prominent comorbidities of troublesome traits? For example, BPD can be found in conjunction with almost any of the other disorders. The challenge to the therapist, the level of treatability, and the prognosis at long-term will vary tremendously, depending on whether the mixture (and with BPD, there is always mixture) is BPD × Avoidant PD, BPD × NPD, BPD × ASPD, etc. (Stone, 1990a). Because there are so many important variables that affect treatability and outcome, any matrix one might try to create that contained all the relevant variables would be multidimensional and bewilderingly complex; one would require ideally thousands of patients with severe personality disorders to permit adequate statistical analysis. This is a forbidding task. One is left having to rely a great deal for one’s guidelines on expert opinion, since compelling scientific data will be hard to gather. We are still left with the question: which therapeutic approach is optimal for which type of severe personality disorder? Here again we are confronted with a

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multiplicity of variables: besides the trait mixtures within each patient, there are the issues of the patient’s cognitive style, culture, and socioeconomic background, etc. Therapist variables enter the equation: level and breadth of training, personal preferences, plus the factors Judd and McGlashan emphasized in connection with treating BPD patients’ namely flexibility, enthusiasm, ethical correctness, ability to contain strong emotion, and the like. If one’s impressions about treatability are derived from review of carefully conducted studies in the literature, were these done with control groups? Were the studies naturalistic or randomized? Were measures taken to assess therapist competence and adherence to the standards set for some particular treatment approach? The lack of uniformity in these matters has made it difficult to assess the advantages and shortcomings of the various popular approaches for treating severe personality disorders. Some of the earlier reports from the 1990s used control groups, but the “treatment as usual” group sometimes received much less time per week with their therapists, creating a situation that automatically favored the approach being tested. The newer randomized studies have usually been better designed: all treatment groups receive approximately equal time with their therapists, and equally experienced therapists, such that the superiority of approach “A” over approach “B” is more likely due to its inherent superiority for the patients in question, than to bias. With these comments in mind, we can see how the current studies inspire the question of not which treatment approach is “best” (across the board) for severe personality disorders, but which approach is ideally suited to which particular types of patients. Can we discern which particular patients would respond better to a behavioral approach, for example, than to a dynamic? Which would respond better to a supportive approach? For whom is a self-psychological approach of the sort developed by Kohut the optimal road to improvement? We do not as yet have answers to these questions, but this is the direction in which contemporary research on the severe personality disorders is headed. Thus far, we have seen from the studies of the past decade on BPD that patients show encouraging levels of improvement and diminution in the number of selfdamaging/self-mutilating acts over the short term with: (1) a step-down psychosocial program (Chiesa and Fonagy, 2003), (2) a self-psychological therapy with BPD outpatients (Stevenson and Meares, 1992), (3) a mentalization-based dynamic therapy in a partial-hospital setting (Bateman and Fonagy, 2004b), as well as with the already cited works of Linehan and her colleagues, using Dialectic Behavior Therapy, and Kernberg and his colleagues, using TFP. Additional studies are underway, evaluating supportive approaches (Winston et al., 2004) and the cognitiveanalytic therapy developed by Anthony Ryle (2004). At this stage it can be said that many BPD patients can be helped by competent therapists schooled in any of the above-mentioned, widely accepted methods. Antisocial traits constitute a limiting

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factor: the stronger the traits, the more negative the effect upon amenability to therapy. About ASPD itself, there is near-universal agreement that a cognitive-behavioral method has the best chance of success; psychodynamic methods, the least chance. Because the definition of ASPD in DSM is polythetic, as with all the disorders, there are combinations associated with greater and less amenability to treatment. Presumably, persons showing item nos. 4, 5, and 7 (aggressiveness, reckless disregard for the safety of others, lack of remorse) would be less accessible to therapy than those with item nos. 1, 3, and 6 (failure to conform to social norms, impulsivity, irresponsibility), inasmuch as the first set of items are closer to the characteristics of the violent psychopath. As for the Cluster-A disorders, each presents tall hurdles to treatability: Schizoid PD because of the aloofness and indifference to others (including potential therapists); Schizotypal PD, because of the marked eccentricity and social anxiety; Paranoid PD, because of the difficulty in forming a trusting relationship with any therapist and because of the tendency to grossly misread the intentions of others, including of course the intentions of the therapist who struggles to correct the distorted views of the patient. The remaining disorders of Cluster-B present their own special difficulties: the Histrionic PD is often associated with impulsive behaviors, chaotic life, irresponsibility, and, in the therapeutic arena, showing up late, missing sessions, and in other ways undermining the continuity and perseverance upon which treatment depends. Narcissistic PD is associated quite often with dismissive attachment style, common results of which are either the disparagement of the therapist or the tendency to quit treatment prematurely, or both. The inhibited types of personality disorder are, as mentioned, usually more amenable to treatment, except in the extreme cases. What remains are the disorders not included in DSM. Their amenability to psychotherapy can be compartmentalized into three groups: (1) other inhibited types: the (classical) hysteric, the depressive, and the depressive-masochistic; (2) disorders of intermediate difficulty: the passive-aggressive and the irritable (or “explosive”); and (3) the least treatable: the psychopathic and the sadistic. There is an important distinction to be made between the irritable and the sadistic. The defining feature of the sadist is the enjoyment of other persons’ suffering. This is by definition ego-syntonic and all but impossible to rectify, especially because empathy will be nil or nearly so. There are irritable persons who impulsively do mean things to others, hit them physically or hurt them psychologically via humiliation, yet are then regretful and capable of remorse. Certain “malignant narcissists” show this pattern: because they have some capacity for loyalty, they can end up feeling bad

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about those whom they have hurt. The ego-dystonic quality of their actions makes irritable persons more likely than the sadist to benefit from treatment. As a final thought, there is a practical aspect to the whole subject of treatability for the severe personality disorders. Inevitably, the numbers of persons exhibiting such disorders will always be significantly greater than the number of therapists who are skilled at dealing with these disorders. There must always be at least a small army of enthusiastic investigators and therapists searching for ways to expand the efficacy of our treatments so as to bring help to greater numbers of personality-disordered patients. At any given time, however, there will be a majority of therapists who, collectively, are prepared to help only a fraction of such patients. They will, for that reason, need to be prepared to devote their efforts to those most amenable to available treatments.

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Michael H. Stone Senol, S., Dereboy, C. and Yuksel, N. (1997). Borderline disorder in Turkey: a 2- to 4- year follow-up. Soc Psychiatry Psychiatric Epidemiol 32: 109–112. Seto, M. C. and Barbaree, H. E. (1999). Psychopathy: treatment behavior & sex offender recidivism. J Interpersonal Violence 14: 1235–1248. Skodol, A. E., Pagano, M. E., Bender, D. S. et al. (2005). Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med 35: 443–451. Soderberg, S., Kullgren, G. and Salander-Renberg, E. (2004). Childhood sexual abuse predicts poor outcome seven years later. Social Psychiatry Psychiatric Epidemiol 39: 916–920. Stevenson, J. and Meares, R. (1992). An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 149: 358–362. Stone, M. H. (1985). Analytically oriented psychotherapy in schizotypal and borderline patients: at the border of treatability. Yale J Biol Med 58: 275–288. Stone, M. H. (1990a). The Fate of Borderlines. New York: Guilford Press. Stone, M. H. (1990b). Long-term follow up of narcissistic personality disorder. Psychiatr Clin N Am 12: 621–641. Stone, M. H. (1993). Long-term outcome of personality disorders. Br J Psychiatry 162: 299–313. Stone, M. H. (1994). Characteristic subtypes of borderline personality disorder. With a note on prognostic factors. Psychiatr Clin North Am 17: 773–784. Stone, M. H. (1996). Schizoid and schizotypal personality disorders. In G. Gabbard and S. Atkinson (eds) Synopsis of Treatments of Psychiatric Disorders, 2nd edn. Washington DC: American Psychiatric Press, pp. 953–957. Stone, M. H. (2001). Serial sexual homicide: biological, psychological and sociological aspects. J Personal Disord 15: 1–18. Stone, M. H. (2006). Personality-Disordered Patients: Treatable and Untreatable. Washington DC: American Psychiatric Press. Stone, M. H., Hurt, S. and Stone, D. K. (1987). The P. I.-500: long-term follow up of borderline inpatients meeting DSM III criteria. J Personal Disord 1: 291–298. Vanggaard, T. (1979). The Borderlands of Sanity. Copenhagen: Munksgaard. Wallerstein, R. (1986). Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy. New York: Guilford Press. Winston, A., Rosenthal, R. N. and Pinsker, H. (2004). Introduction to Supportive Psychotherapy. Washington DC: American Psychiatric Press. Yen, S., Pagano, M. E., Shea, M. T. et al. (2005). Recent life-events preceding suicide attempts in a personality disorder sample: findings from the collaborative longitudinal personality study. J Consult Clin Psychol 73: 99–105. Zadeh, L. (1987). Coping with the imprecision of the real world. In R. Yager, S. Ovchinnikov, R. Tong and H. Nguyen (eds) Fuzzy Sets & Applications: Selected Papers by L. A. Zadeh. New York: John Wiley and Sons. Zanarini, M. C., Frankenburg, F. R., Hennen, J. and Silk, K. R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 160: 274–283.

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Treatability in severe personality disorders Zanarini, M. C., Frankenburg, F. R., Vujanovic, A. A., Hennen, J., Reich, D. B. and Silk, K. R. (2004). Axis-II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission. Acta Psychiatrica Scand 110: 416–420. Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B. and Silk, K. R. (2005). Psychosocial functioning of borderline patients and Axis-II comparison subjects followed prospectively for 6 years. J Personal Disord 19: 19–29. Zweig-Frank, H. and Paris, J. (2002). Predictors of outcome in a 27-year follow-up of patients with borderline personality disorder. Compr Psychiatry 43: 103–107.

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The treatment of choice: what method fits whom? John F. Clarkin

Two dominant methods can be utilized today for matching the individual patient with the most optimal treatment. The method receiving extensive attention at this time is the empirically supported treatment movement (Chambless and Hollon, 1998). In this methodology, the patient who presents with a particular DSM disorder is matched with a therapist who is armed with a specific treatment, usually cognitive-behavioral, that will focus on and alleviate the symptom in a brief period of time. The suggestion that it is unethical to do otherwise implies that our training programs for clinicians should be focused on this match of patient symptoms with cognitive-behavioral technology. However, a number of issues make one pause and resist joining the band-wagon of the empirically supported psychotherapy movement: r Most patients present with more than one, clearly defined, DSM disorder. This is especially true of those individuals with severe personality disorders. r Focused cognitive-behavioral treatments are limited in their effectiveness in the short-run, and often seem inadequate in the long-run. At termination from short-term treatment, a majority but not all patients has been helped with his/her symptoms. Upon follow-up, a much smaller group of patients has maintained their gains (Westen and Morrison, 2001). r The emphasis on therapy as a set of technical interventions tends to ignore the attributes of the therapist beyond just his/her skill in delivering specific techniques. This metaphor of a therapist as a dispenser of techniques leads logically to a computer providing programmed direction. r If a treatment fails and the patient drops out prematurely, it is often assumed that the patient’s characteristics are the major contributor to the disruption. We have examined data describing such patients, including but not limited to diagnosis (Clarkin and Levy, 2004). The therapist’s contribution to the failure has been less frequently examined.  C Cambridge University Press 2007

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The second systematic method for treatment selection has been called differential therapeutics (Frances et al., 1984) and differential treatment planning (Beutler and Clarkin, 1990; Beutler et al., 2000). In this approach, existing research is utilized, but in a clinical context bounded by treatment resources available, patient characteristics that influence treatment beyond just the patient’s diagnosis, and recognition that not all therapists are alike or totally described by their treatment orientation. The first approach places emphasis on the power of particular interventions, and, by omission, assumes that the therapist is competent to deliver the interventions. The second approach assumes that the therapist is a professional who uses judgement to select and utilize interventions according to the individual patient. This chapter on the most optimal treatment for the individual patient with severe personality disorder is in the spirit of the second approach. (This approach is also congruent with the Zon and Schild project to video tape the assessment of the same patient by a variety of master clinicians, all of whom bring somewhat different approaches to the unique patient.) The first approach is premature and simplistic, especially with our limited empirical knowledge about the treatment of patients with complicated and severe personality pathology. Treatment choices facing the clinician The diagnostician is faced with an array of issues in choosing a treatment for the individual patient with severe personality pathology because patients with severe personality disorders are: (1) diverse at the diagnostic level; (2) diverse in their investments in intimate relationships and work; (3) variable in terms of nondiagnostic characteristics that have been identified by theory (e.g., symbolic activity, degree of mentalization, attachment status, aggression, moral values, ratio of positive and negative affect, constraint); and (4) vary in motivation for change and the resources they have for engagement in treatment. Furthermore, the clinician is faced with a diversity of treatment models – cognitive-behavioral, mentalization based, psychodynamic – which identify and focus on different outcome goals and mechanisms of change. The research to date on these treatments has focused on group means, and has not isolated individual patients who do not respond to the treatment in question. We know that not all patients respond to each of these treatments. Finally, diagnosticians assessing the individual patient with severe personality disorders are often in a situation of referring the patient to a particular clinician who will carry out the treatment. To which clinician does the diagnostician refer the patient? Discussion among clinicians involved in referral of patients suggests that there is often an attempt to match the characteristics of the patient with some of the personality qualities of the prospective therapist.

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Patient heterogeneity Diagnostic variability

Because the DSM diagnostic system is polythetic (i.e., the diagnosis is made if a certain number of criteria are met out of a larger set of diagnostic criteria), borderline patients are variable even at the diagnostic level. These differences might be important for treatment selection. For example, Linehan (1993) has developed a treatment for those borderline patients with active suicidal behavior, but not all borderlines have current or past suicidal behavior. Furthermore, just at the level of personality pathology alone, most borderline patients are “comorbid” for several other Axis II disorders. Kernberg (Kernberg and Caligor, 2005) has posited that the comorbid Axis II disorders are not random, but fit into a model of personality pathology characterized by both categories of organization (neurotic personality organization, high-level and low-level borderline personality organization), and dimensions such as internalization and externalization.

Patient characteristics other than diagnosis Several patient characteristics have an important impact on therapy process and outcome (Clarkin and Levy, 2004). In addition, models of personality pathology (Lenzenweger and Clarkin, 2005) posit patient characteristics not encompassed in the diagnostic system but central to the pathology and thus to intervention. Emphasis on the individual’s conception of self and others in a relationship is an emerging central theme in these various approaches to personality pathology. For example, the cognitive model (Pretzer and Beck, 2005) focuses on the schemas of self and others, and suggests that personality malfunction is related to attributional errors in the schemas relating to self and others. An attachment model of personality and its disorders (Meyer and Pilkonis, 2005) suggests developmental pathways from early secure attachments to sensitive and empathic engagement with others, including loyal friendships. In contrast, early insecure attachments lead to either anxiety-prone relations, or alienation and angry reactions to others. The social isolation experienced by the insecure groups is a pathogenic stressor in itself. What become stable in the individual are networks of cognitive and affective units that guide behavior across contexts. These cognitive and affective units are mental representations of self and others, and involve the goals and strategies to pursue them. These units can become activated automatically in daily situations, beyond conscious awareness. Cognitive and attachment models of personality pathology have much in common with the object relations models (Kernberg and Caligor, 2005). Bateman and Fonagy (2004) add to this complexity by arguing that borderline personality

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disorder (BPD) patients are not capable of secondary affect representation, so they must be assisted in developing skills in conceptualizing self and others. Their argument is interesting, but needs empirical data on the levels of affect representation across borderline patients. Our data (Clarkin and Posner, 2005) indicate that BPD patients are heterogeneous for neurocognitive tasks, effortful control, and attachment style, suggesting they might also be heterogeneous on affect representation. Which treatment model? What treatment model does the clinician utilize for the individual patient? Does he/she choose one treatment model, and become proficient in that, or does he/she become proficient in several and attempt to apply the models selectively to different patients? Clinicians have their own preferences in terms of treatment models based on comfort level and expertise. The treatment models for BPD range from cognitive-behavioral (Linehan, 1993), through cognitive (Pretzer and Beck, 2005), to psychodynamic (Bateman and Fonagy, 2004; Clarkin et al., 2006). Each of these treatments helps some patients and not others. Each of the treatments has the goal of clinical change, with different and unique conceptions of the mechanisms of change or how the specific treatment model works. In this chapter, we are raising further complications: not only how does the treatment in question work, but how does it work in the hands of a specific therapist? Roth and Fonagy (2005) provide an excellent review of the research in choosing treatments for severe personality disorders, including borderline personality disorder. They emphasize that the structure of the treatment for these patients suffering affective instability and impulsivity is crucial. They acknowledge it is difficult to experimentally disentangle the treatment structure from the other operative factors in the cognitive behavioral and psychodynamic treatments. It seems reasonable that both the particular therapist and the treatment model used by the therapist will provide structure and orientation to the treatment of a specific patient. Furthermore, the research of Wampold (2001) provides a context in which one can judge the relative merits of the treatment orientation and the characteristics of the therapist. Match between therapist and patient in transference-focused psychotherapy (TFP) Research on patient–therapist match

There is a body of research on the patient–therapist match that suggests this is an important area of contribution to the variance in therapy outcome. In a recent

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thorough review of therapist variables and their relative contribution to outcome, Beutler et al. (2004) observed a decline in research on therapist variables, with the majority of research interest focused currently on particular therapist techniques and interventions. This research focus dominates and persists, despite the fact that therapist techniques only account for a minor part of the variance in outcome. In terms of therapist variables, other than use of specific treatment techniques, the reviewers found the following: (1) therapist sex, age, and race are poor predictors of treatment outcome; (2) therapist training, skill, experience and style are weak and variable contributors to outcome; (3) a significant, though modest, effect size is associated with therapist well-being and cultural attitudes: it would appear that the difference between the attitudes and values of the therapist and patient actually stimulates patient change; (4) therapists’ relationship qualities and model of treatment contribute a moderately strong effect size. These reviewers conclude that the enormous energy put into examining uniquely effective procedures within treatment models is misplaced, as classes of procedures do not have uniform effects. The reviewers suggest it is imperative to integrate patient, therapist, procedural, and relationship factors in future research. In our extensive study of the psychodynamic treatment of patients with BPD (Clarkin et al., 2004), we have been impressed with the value of closely examining the course of individual treatments. Change in a group of patients is important, but individual patient change in a unique relationship with a specific therapist provides a different view of a complex situation. We have described a treatment model (TFP) in terms of goals of treatment, mechanisms of change, and strategies, tactics, and techniques (Clarkin et al., 2006). Following assessment, the therapist negotiates a treatment contract with the patient that introduces the structure of expected patient and therapist behaviors and responsibilities in the treatment. With the aid of the treatment contract, patient acting-out behavior is reduced and focus is on the dominant object relations that are manifested in the interaction between therapist and patient. There are impediments to this kind of in-depth examination of a particular patient–therapist interaction. First of all, we have become accustomed to asking our patients, with proper notification and signing of informed consent, to provide personal information about their symptoms, their early experiences, and their relationships over time. We ask them in detail about the progression of their symptoms throughout treatment, and sometimes ask them about the relationship they experience with their therapist. However, we are reluctant to ask such information from therapists. Our own experience at the Personality Disorders Institute is that only with careful induction and group process can one introduce the videotaping of therapy sessions. We have recently extended this examination of the therapist by introducing

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a revision of the Adult Attachment Interview (AAI), which focuses on the nature of early relationships, into a Patient Therapist AAI (PT-AAI), which focuses on the relationship between patient and therapist. Like the AAI, the PT-AAI is a semistructured interview. The aim is to assess states of mind with regard to attachment, or the conscious and unconscious rules used by the participants for organizing the relationship between patient and therapist, rather than the parent–child relationship. We have examined the relationship between one therapist treating two borderline patients with a manualized psychodynamic treatment (TFP) (Diamond et al., 2003). In this way, we were able to control for the personality of the therapist and the treatment model, but compare across two patients with the same diagnosis (BPD). There was no attempt to match particular therapists with particular patients in this study. Thus, the patients met the diagnostic criteria, and were randomized to TFP and the therapist with openings was assigned to this particular individual. In both cases, the therapist was a male psychiatrist trained in TFP, and the patients were females in their early 30s with the diagnosis of BPD. In contrast to prior studies of the match between patient and therapist, we did not use extensive self-report questionnaires on patients and therapists. We opted for the methodology of a semi-structured interview, the AAI, which focuses on the attachment history and events experienced by the individual, in this case the patient, and significant others such as infant caregivers. The AAI provides information on the patient’s attachment status to early parental figures, which may or may not provide a template for relations later in life. In addition, we used the PT-AAI to gather information from the patient in reference to his/her experience of the relationship with the therapist, and to gather information from the therapist on his conception of the relationship with the particular patient. This seemed clinically appropriate and potentially rich in information, given that the therapy (TFP) was intensive in its contacts (two times a week sessions for at least one year in duration), with the intent of stimulating a relationship between therapist and patient that would provide an opportunity for the arousal of the patient’s dominant object relations which would be explored in depth by patient and therapist. This model can be described as a three-person therapy in which the therapist is both the object of the patient’s projections, and at the same time a third person observing the dominant object relations as they are aroused and played out in the transference. We hypothesized that the PT-AAI material might provide a window into the patient’s perception of the therapist both in role (with therapeutic neutrality) and contaminated by the projections that the patient makes, especially in the early phases of the treatment. At the same time, the PT-AAI with the therapist provides the therapist’s view of himself both in role with the patient, and with the conceptualizations of patient/therapist interaction in his mind.

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The two patients were both White women in their mid 30s with a number of hospitalizations for self-destructive and suicidal behavior prior to entering TFP. We focus here on data from the AAI (attachment status, reflective functioning), and the PT-AAI (patients’ conception of therapist; therapist’s conception of patient) prior to and after one year of treatment. The close examination of several individual patients enables one to see the important differences even within the same BPD diagnostic category, and provides a closer look at how change is an individual process. Patient A

Patient A was a married woman diagnosed by DSM criteria with BPD and prominent narcissistic and antisocial features. Prior to treatment Patient A had a primary attachment classification of unresolved for trauma (U) and a secondary classification of preoccupied (E) with specific subtypes of fearfully preoccupied with traumatic events (E3) and angry and conflicted (E2) on the AAI. She manifested disorganization and incoherence in her verbalizations when discussing past attachment-related traumas, and indicated that these experiences were interfering in her current functioning (preoccupied). Her level of reflective functioning prior to treatment was rated as 1, which is very low and indicative of rudimentary conceptions of self and others. Overall, our clinical impression was that treatment would be difficult and prognosis was guarded. Borderline patients with comorbid narcissistic and antisocial features present complicated transference relationships that are potentially marked by destruction of the therapist’s communications and dishonesty. Her suicidal behavior in the past was extensive. The reflective functioning score was quite low, and suggested she might not be able to use interpretations. After one year of TFP the patient had made substantial behavioral and symptomatic gains. She was no longer exhibiting suicidal behavior, and her relationship with her husband had improved. She was now classified on the AAI as securely attached with a subclassification (F5) indicating coherence and autonomy but remaining at the preoccupied end of the secure spectrum. Thus, she remained somewhat angrily entangled with attachment figures, but with a high degree of coherence, insight, humor, and growing acceptance and understanding of her own and her parents’ foibles. At time 2, her reflective functioning had changed from a 1 to a 5, indicating an advance to ordinary or average level of reflection. Thus, from several points of view, we considered this treatment a success. Symptoms and behavior had improved, her attachment classification had changed from insecure to secure, and her ability to articulate a working conception of self and other (reflective functioning) had improved substantially. We examined the data from the PT-AAI after one year of treatment to yield information about the nuances of the relationship between therapist and Patient

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A. From all objective diagnostic information, Patient A was more disturbed than Patient B prior to treatment, and would appear to have the least favorable prognosis of the two. However, the data indicate that the therapist and Patient A, though engaged in a stormy treatment course, experienced a relationship that was conducive to change. Patient A was rated on the PT-AAI as having a secure state of mind in reference to her therapist, although she was somewhat resentful and conflicted leading to a rating of F5. In response to a request for five adjectives, she described her relationship with the therapist as “reliable, dignified, important, mildly frustrating, and confusing,” and could illustrate the adjectives with clear examples. She felt initially that the therapist would forget her between sessions, but gradually she began to trust him more. She said that in the beginning of therapy she was skeptical of a contract, and fearful that things would be too strict. She began to realize that the contract was there, and did not have to come up often. She thought the therapist was cold and only interested in the research, and not in her. In reaction, she was not forthcoming with the therapist, acted “tricky” with him, but at the same time realizing she was wasting her time. Gradually, a mutual respect grew, and she no longer tried to outsmart him, and “all the bullshit parts of me” went home to rest. Asked about separations from the therapist during the treatment, she said they were “stressful” and at times “seemingly endless” but that she gradually began to manage them more easily. Her comments, however, illustrate her ambivalence about dependence and separation. During the last separation, she quit smoking to show she was not bothered by it, but also began thinking she needed a new therapist. She surmised that she might have been a little angry. When asked how the relationship with the therapist had affected her personally, she articulated what might be considered a statement about finding a secure base in their relationship. She said she has felt a little more secure in general because the therapist has been so reliable and a steadying influence, the kind of security one might find in “a home when you’re a kid.” Patient responses on the PT-AAI illustrate the conceptualization that the patient’s internalization of the experience of having another (the therapist) reflecting on one’s own inner life leads to the growth of self reflection and the appreciation of the mind of the other. They also reflect Bowlby’s (1988) conception of therapy providing a secure base. We would add that the security of a relationship provides a safe setting in which an individual can articulate a new sense of self and the other (therapist) in a helpful, cooperative relationship. Patient A’s therapist was asked for five adjectives to describe his relationship with Patient A, and he said the relationship was very committed, stable, quite seductive from her to him, and enjoyable. In terms of committed, he noted that her attendance at therapy was perfect and she was always on time for sessions. Her whole

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approach to treatment seemed committed. The therapist, in his own descriptions, seems to have created a balance between finding her interesting and enjoyable, and furthermore finding her seductive but not becoming overwhelmed or lulled into a false security in that. He noted that the sessions were like a Noel Coward play with sophisticated charm and humor, but under the surface was lurking a Stephen King novel. In his view, Patient A craved approval and love, and wanted someone to provide her with the love and admiration that she did not have either from herself or her parents. The other impulse was to become enraged if she did not find such affection. The therapist made it clear that he liked her, saw her as very bright and clever, witty and engaging. One might infer that the patient realized at some point in the treatment that the therapist was not only consistent and stable, but that he was not seduced by her and yet still found her engaging and valued her. The therapist did not see her aggression as something to run from (although somewhat frightening), but understandable given her background, and something that he could consistently tolerate in the relationship, and yet interpret. The therapist saw the patient improving by internalizing the notion that her aggression is present all the time, and realizing that it’s better not to deny it but rather modulate it, enriching a sense of herself as complex, rather than a grandiose self at times and a psychiatric patient at other times. Patient B

Like Patient A, Patient B was also diagnosed BPD but without narcissistic and antisocial features. Early in treatment, Patient B had a classification of dismissing (D) with a subtype of devaluing of attachment (D2) on the AAI. This classification reflects her derogatory and detached description of her parents, while minimizing the significance of feelings and affects linked to early attachment experiences, and to the importance of attachment relationships in general. At the end of one year of TFP, Patient B was symptomatically improved with no further suicidal behavior. She had an attachment classification of secure with some devaluing of attachment relationships and at the dismissing end of the secure category (subclassification of F1A). Like Patient A, Patient B had a reflective functioning score of 1, a very low rating, prior to treatment. However, in contrast to Patient A, Patient B showed no change in her poor reflective functioning after one year of TFP. Her description of the therapist after one year of treatment reflects concerns about boundaries, distance and control with a defensive concreteness. She said she did not really know him, as he keeps an impartial distance. He was matter of fact, nice, a doctor. In a parallel fashion, the therapist experienced the relationship with Patient B as distant, rigid, formal, cold, and superficial. He saw her as not wanting him to probe very far. She was in treatment because she had to be there, almost

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against her will, but attempted to behave. (She was well dressed, very tasteful, almost like she was at a tea party with proper behavior.) She spent much of the therapeutic interchange discussing minutiae about her work. The therapist felt there was hardly ever any expression of affect toward him, and she experienced separations in the treatment without much reaction. Summary and comparison In this attempt to contrast the two patients and their trajectory of treatment with the same therapist, what emerges is a conception of potential patient change at various levels. Symptomatically, both patients improved. Patient A decreased considerably in suicidal and self-destructive behavior. Patient B had made a sudden, surprising suicidal act that had brought her to treatment, and there was no re-emergence of that in our treatment. However, at the level of reflective functioning the two patients were quite different in treatment outcome. Patient A made considerable gains in the ability to reflect about conceptions of self in relation to others, whereas Patient B made no change in this regard. This difference in the two patients was clearly reflected in their conception of the therapist and the therapist’s conception of the patient and what occurred in the treatment. Patient A grew in trust and openness with the therapist, whereas Patient B remained distant and silent, despite the attempts of the therapist to enter her inner world. It would appear that Patient A changed not only in symptoms and behavior, but also at the level of her internalized schemas, cognitive-affective units, and object relations. Her internalized working model of herself and others, and her relationships had expanded, thus providing her with more nuanced flexibility in relating to others. It remains for future empirical research to ascertain whether the change at the level of internal object relations is predictive of continued maintenance of gains in treatment for borderline patients. To return to the question of the match between patient and therapist, one might surmise that the match between this therapist with his appreciation and tolerance of both the disturbed aspects of Patient A and her charm, wit and intelligence enabled him to become engaged with her in a relationship that allowed her to articulate a more integrated sense of herself and others. In contrast, the match between the therapist, the TFP treatment model, and Patient B led to symptom change without change in the capacity to reflect on self and others in a more amplified way. Was this a good treatment match? Could a different therapist have entered more into this patient’s world? Or, would the patient have profited more from a more objective, skills-oriented approach like Dialectical Behavior Therapy? Only with additional careful research will clinical guidelines for the treatment of borderline patients and others with a combination of severe personality disorders become clear. For this clarity to emerge, a number of developments, now in nascent

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form, must evolve: (1) a diagnostic system for personality disorders less dependent on symptoms and behaviors, and more focused on functions and capabilities (e.g., effortful control, identity construction, reflective capacity); (2) treatment outcome research that carefully examines maintenance of gains beyond treatment termination; (3) attention to expert therapists and their use of strategies with individual patients; and (4) assessment not just of treatment outcome but the mechanisms of change.

R E F EREN CES Bateman, A., and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-based Treatment. Oxford: Oxford University Press. Beutler, L. E. and Clarkin, J. F. (1990). Systematic Treatment Selection: Toward Targeted Therapeutic Interventions. New York: Brunner/Mazel. Beutler, L. E., Clarkin, J. F. and Bonger, B. (2000). Guidelines for the systematic treatment of the depressed patient. New York: Oxford University Press. Beutler, L. E., Malik, M., Shabia, A., Harwood, T. M., Talebi, H., Noble, S. and Wong, E. (2004). Therapist variables. In M. Lambert (ed.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 5th edn. New York: Wiley, pp. 227–306. Bowlby, J. (1988). A Secure Base. New York: Basic Books. Chambless, D. L. and Hollon, S. D. (1998). Defining empirically supported therapies. J Consult Clin Psychol 66: 7–18. Clarkin, J. F. and Levy, K. N. (2004). The influence of client variables on psychotherapy. In M. J. Lambert (ed.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 5th edn. New York: Wiley, pp. 194–226. Clarkin, J. F. and Posner, M. (eds.) (2005). Special topic section: borderline personality disorder. Psychopathology 38: 53–86. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F. and Kernberg, O. F. (2004). The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics. J Personal Disord 18(1): 52–72. Clarkin, J. F., Yeomans, F. K. and Kernberg, O. F. (2006). Psychotherapy for Borderline Personality: Focus on Object Relations. Washington DC: American Psychiatric Press. Diamond, D., Clarkin, J. F., Stovall-McClough, C., Levy, K. N., Foelsch, P., Levine, H. and Yeomans, F. (2003). Patient–therapist attachment: impact on therapeutic process and outcome. In M. Cortina, M. Marrone (eds.) Attachment Theory and the Psychoanalytic Process. London: Whurr Press, pp. 179–203. Frances, A., Clarkin, J. and Perry, S. (1984). Differential Therapeutics in Psychiatry: The Art and Science of Treatment Selection. New York: Guilford Press. Kernberg, O. F. and Caligor, E. (2005). A psychoanalytic theory of personality disorders. In M. F. Lenzenweger and J. F. Clarkin (eds.) Major Theories of Personality Disorder, 2nd edn. New York: Guilford Press, pp. 114–156.

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The treatment of choice: what method fits whom? Lenzenweger, M. F. and Clarkin, J. F. (eds.) (2005). Major Theories of Personality Disorder, 2nd edn. New York: Guilford Press. Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Meyer, B. and Pilkonis, P. A. (2005). An attachment model of personality disorders. In M. F. Lenzenweger and J. F. Clarkin (eds.) Major Theories of Personality Disorder. New York: Guilford Press, pp. 231–281. Pretzer, J. L. and Beck, A. T. (2005). A cognitive theory of personality disorders. In M. F. Lenzenweger and J. F. Clarkin (eds.) Major Theories of Personality Disorder. New York: Guilford Press, pp. 43–113. Roth, A. and Fonagy, P. (2005). What Works for Whom?, 2nd edn. New York: Guilford Press. Wampold, B. (2001). The Great Psychotherapy Debate: Models, Methods, and Findings. Mahwah, N.J.: Erlbaum. Westen, D. and Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies. J Consult Clin Psychol 69: 875–899.

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Countertransference: recent developments and technical implications for the treatment of patients with severe personality disorders Otto F. Kernberg

What follows is an overview of the clinical experiences regarding countertransference that we have gathered over 25 years in the treatment of severe personality disorders at the Personality Disorders Institute of the Weill Cornell Medical College and the Westchester Division of the New York Hospital. Earlier experiences of the author in his work with the psychotherapy research project of the Menninger Foundation provided the conceptual and clinical background that influenced the development of new technical approaches and the reshaping of the relevant concepts.

The contemporary concept of countertransference At this time, the “totalistic” or “global” concept of countertransference clearly has replaced the classical concept as originally defined by Freud (1910). The classical concept defined countertransference as the analyst’s transferences toward the patient, or the analyst’s unconscious reactions to the patient’s transference; the accent was on the unconscious aspect of the analyst’s reaction, with the implication that only further analytic work by the analyst on himself would help him to “overcome” the countertransference, as Freud recommended. The contemporary “totalistic” or “global” concept, in contrast, defines countertransference as the therapist’s total emotional reaction to the patient at any particular point in time (Kernberg, 1975). The implication of this modern, contemporary concept is that the therapist needs to monitor his/her countertransference consistently to deepen the understanding of the patient by relating it to the developments in the transference. For practical purposes, in fact, often, nowadays, the process of psychoanalysis and psychoanalytic psychotherapy is described as the gradual development of transference/countertransference binds in the context of a boundary controlled  C Cambridge University Press 2007

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psychotherapeutic interaction within which the therapist attempts to maintain a position of technical neutrality. In this connection, it needs to be stressed, the concept of technical neutrality is often misinterpreted as implying a “studied indifference,” suggesting a lack of appropriate investment and concern on the part of the therapist. In reality, technical neutrality refers to the therapist’s interventions as remaining neutral regarding the intrapsychic conflicts of the patient; or, more concretely, neutral in relation to the patient’s superego, id, acting ego, and external reality. Technical neutrality implies a concerned objectivity characterized by interpretive interventions from the position of an alliance with the observing part of the patient’s ego. This classical definition of technical neutrality, first formulated in this form by Anna Freud (1936), still holds, I believe, as a necessary precondition for the analysis of countertransference reactions, rather than simply acting them out. The therapist is not “neutral” in terms of not having emotional reactions to the patient, but in his/her effort and capacity to contain them, and use them for a better understanding of the therapeutic situation rather than discharging these emotions in the relationship with the patient. It is well known that, in the psychoanalytic psychotherapy of patients with severe regression in the transference, countertransference acting out may, at times, be unavoidable, and constitute a special complication in the management of the treat´ and R. Bernardi ment of these patients, to which I shall return. As B. DeLeon have pointed out in their unpublished manuscript, “Countertransference and the vulnerability of the analyst,” the contemporary concern with countertransference should not be overly broadened to include the analyst’s general disposition toward self-analysis and his/her reflective ability to understand what goes on in his/her mind as well as in that of the patient. These authors also caution us against the tendency to expand the utilization of countertransference to the extent of favoring narcissistic self involvement of the therapist. Returning to the classical concept of countertransference, it should be kept in mind that Freud’s introduction of the term countertransference, together with his stress on the need to “overcome” it, reflected his reaction to the frequency of boundary violations by his early male disciples leading to their sexual involvement with female patients. That early threatening experience determined a counterphobic attitude toward this concept, lasting from the 1910s to the 1950s, reflecting, I believe, the hidden concern over those past boundary violations within the psychoanalytic community. As is well known, it was only in the 1950s that new, significant contributions opened the field of countertransference to its contemporary enrichment of psychoanalytic and psychotherapeutic theory and technique. Here the contribution of Paula Heimann (1950), pointing to the projection of the patient’s unconscious experiences as part of the countertransference reaction of the psychoanalyst and to the analysis of countertransference as a significant contribution to clarifying

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transference developments, was an important landmark. The contributions of the Argentinean school, particularly by Racker (1957), Madeleine and Willie Baranger (1961–1962, 1969) and Baranger et al. (1982), further expanded the field of countertransference analysis and the utilization of it in treatment. It was particularly Racker’s clarification of concordant and complementary identification in the countertransference that provided the most important, practical clinical applications of the new understanding of countertransference as a composite structure, constituted by aspects of both the patient’s and the analyst’s conscious and unconscious contributions. In effect, the contemporary concept of countertransference implies that the therapist’s moment-to-moment emotional reaction to the patient is co-determined by (1) the patient’s transference, (2) reality aspects of the patient’s life, (3) reality aspects of the therapist’s life that may be influenced directly or indirectly by the patient, and (4) the therapist’s countertransference disposition in a restricted sense, as defined by the classical concept. What I have stressed in earlier work, based on these contributions to our understanding of the countertransference stemming from the 1950s on, is the fact that the more severe the patient’s psychopathology, the more the countertransference is determined by the patient’s transference; so that, in practice, countertransference analysis has become a fundamental instrument for the understanding in depth of transference developments of borderline pathology (Kernberg, 1976). As we described it in our manual, Psychotherapy for Personality Disorders (Clarkin et al., 1999), Transference-Focused Psychotherapy (TFP) was developed at the Cornell Personality Disorders Institute as a modified psychodynamic psychotherapy for severe personality disorders. In TFP, the material that constitutes the raw data for the analysis of the patient’s moment-to-moment transference developments is expressed by means of the patient’s verbal communication, his/her non-verbal communication, and the countertransference. In summary, when dealing with borderline or severely regressed patients, in contrast to those presenting less severe personality disorders, the therapist tends to experience, rather soon in the treatment, intense emotional reactions, having more to do with the patient’s premature, intense and chaotic transferences and with the therapist’s capacity to withstand psychological stress and anxiety, than with any specific problem of the therapist’s past. Thus, countertransference becomes an important diagnostic tool, which provides information as to the degree of regression in the patient, his/her predominant emotional position in relation to the therapist, and the changes occurring in this position. The more intense and premature the therapist’s emotional reaction to the patient, the more threatening it becomes to the therapist’s neutrality, and the more it has a quickly changing, fluctuating and chaotic nature, the more we can think the therapist is in the presence of a severe personality disorder or a severe regression in the patient.

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Classification of countertransference with particular implications for the treatment of severe personality disorders The previously mentioned classification of countertransference into concordant and complementary identifications by Racker is of fundamental importance. Concordant identification, in which the therapist emotionally identifies with the patient’s central subjective experience, “self with self,” corresponds particularly to ordinary empathy, and reflects the therapist’s capacity to share the patient’s experience in the transference. It leads to deepening of emotional understanding on the part of the therapist, and to the patient’s sense of being understood; its risk is an excessive identification with a patient, that may correspond to conscious or unconscious seductive efforts by the patient or to a resonance with the patient’s experience of a reactivated conflict from the therapist’s past. Such an “over-identification” of the therapist with the patient may lead to countertransference acting out, and, insofar as the therapist is tempted to share with the patient a common denial of a particular aspect of the patient’s psychic reality, to “bastions” in the therapeutic situation. Bastions are areas of unconscious collusion between patient and therapist, determining a “blind spot” in the therapist’s understanding (Baranger and Baranger, 1969). Such unconscious collusions between patient and therapist, as ´ and Bernardi (2005) have recently pointed out, may constitute problems DeLeon particularly with traumatized patients, for example victims of political persecution and torture. One related problem is the patient’s and the therapist’s sharing of a socially or culturally determined bias or prejudice, which may restrict the analytic work. For example, if a patient has been persecuted politically, subjected to torture or other highly traumatic experiences, and both patient and therapist share the same political ideology, a “bastion” may evolve that may significantly hamper the deeper aspects of the psychotherapeutic work. Complementary identification in the countertransference is, as a practical matter, the most important form that countertransference dispositions take in the treatment of patients with severe personality disorders. The mechanism of projective identification is the principal defensive operation by means of which patients induce complementary identification in the countertransference. Here the therapist identifies with what the patient cannot tolerate in himself/herself and is projecting onto the therapist, while the patient complements this projection with an unconscious role induction of the therapist to facilitate his/her identification with that projected aspect. Simultaneously, the patient attempts to control the therapist in order to neutralize the dangerousness of that which is projected, most frequently related to intense, primitive aggressive impulses. It needs to be stressed, however, that projective identification does not always elicit complementary identification in the countertransference, and that, at times, complementary identification may

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evolve in sessions with a patient who is not utilizing the mechanism of projective identification at that point. In other words, it is important to avoid an excessive extension of the concept of projective identification, including the complementary countertransference response as part of it. Joseph Sandler’s (1976) concept of the “role responsiveness” of the analyst refers to how certain projections by the patient may resonate with particular dispositions in the psychoanalyst and become part of countertransference responses. When treating some patients with severe personality disorders and corresponding severe regression in the transference, particularly intense, primitive aggression is directed at the therapist for a protracted time. The therapist’s habitual defenses against aggression, from both external and intrapsychic sources, may become activated, so that he/she may appear to have “reactivated” his/her most conflictual characteristics in the treatment of a particular patient. Such developments are also part of chronic countertransference reactions, to which I shall return, and require careful and sometimes painful self analysis by the therapist outside the sessions with a patient, or, of course, consultation. In this connection, I do not believe that any therapist is free from such developments, and from the need occasionally to consult with a trusted colleague in the course of the treatment of very sick patients. Although intense projective identification and the resulting complementary identification in the countertransference may be disturbing, anxiety-producing developments in the sessions, they are potentially of great value in identifying the nature of the dominant object relationship activated in the transference. In a concordant identification in the countertransference, the therapist’s self is identified with the patient’s self experience at that moment. In a complementary countertransference, the therapist may be identified with the patient’s object representation, while the patient identifies with his/her self representation; alternatively, the therapist may be identified with the patient’s projected self representation while the patient is enacting his/her identification with the object representation of the corresponding dyadic unit. In this regard, then, the analysis of complementary countertransference is a powerful tool to clarify the nature of the activation of specific object relations in the transference. A young man who was failing in his studies at college because of an attitude of contempt toward teachers and books, with attendant fantasies of not having to study to understand and know everything, came to a session seriously disturbed because he had just learned that he had failed a major test. He was quite dejected, felt like a failure, and thought that he was going to be depreciated by teachers and his colleagues. I, on the other hand, struggled with an internal reaction of “I told you so,” the sense that this failure served him well after my unsuccessful efforts to confront him with the dangerous, self-destructive nature of neglecting his studies. On further reflection, it seemed to me that he was now enacting, in his experience

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of despair and the fear of being depreciated and devalued by others, his worthless, inferior, depreciated self, while now projecting the grandiose, derogatory aspects of his self onto his classmates, and, I wondered, presumably also onto me. I thought that I was in the position of a projected aspect of his grandiose self, condensed with a primitive, sadistic superego image. I wondered with him whether his disturbance in this session also might be related to his attributing to me both an attitude of devaluation of him and a highly critical, sadistic, triumphant sense of superiority because I had forewarned him regarding the neglect of his studies. The patient immediately was able to recognize these aspects of his internal world projected onto me. As we explored his experience of me it also became apparent that he could not conceive, at this point, that there was an authentic concern for him in my confronting him with the neglect of his studies. The defensive nature of his grandiose self against a profound conviction of not being loved by his mother could only be explored much later. On the negative side, an excessive intensity of complementary identification in the therapist may evolve into “projective counteridentification,” a concept coined by Leon Grinberg (1956, 1979), to refer to the analyst’s “getting stuck” in an unconscious identification with the patient’s projective identification – being unable, therefore, to carry out the internal division between the emotional enactment in the countertransference and the secondary self reflection that is part of the analytic task. This situation relates to one other aspect of countertransference that deserves further exploration; namely, the difference between acute countertransferences – countertransferences that vary from moment to moment in the therapeutic situation – and chronic countertransferences, which distort the experience of the patient in the therapist’s mind over an extended period of time (Kernberg, 2004a). The latter represent a chronic “blind spot,” of which the therapist may gradually become aware, without, at first, being able to resolve it. It is particularly with patients presenting severe personality disorders where such development of chronic countertransference reactions is frequent, and, as I pointed out in an earlier work (Kernberg, 1999), requires self-exploration by the therapist outside the sessions, or consultation. I believe this situation needs to be differentiated from momentary projective counteridentification and potential acting out of the countertransference under conditions of severe, regressive acting out of the transference in the sessions: here projective counteridentification is a transitory phenomenon, that can be analyzed and resolved in the course of the same or a few sessions. In short, the analysis of countertransference in terms of its concordant or complementary nature, and in terms of its moment-to-moment fluctuating nature in contrast to chronic transference developments reflects two major, clinically useful classifications of countertransference reactions. These distinctions, at times, may not be so easy to establish quickly, and require reflection regarding the countertransference,

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both in an ongoing process of the therapist analyzing his/her sources of information (the patient’s verbal communication, their non-verbal communication, and the therapist’s countertransference) but also require the analysis of what happens with the patient’s material in the therapist’s mind outside the sessions. As Tower (1956) observed many years ago, chronic countertransference reactions may emerge so discreetly and gradually that, at times, the analyst only becomes aware of them retrospectively, as the successful resolution of a transference stalemate reveals a chronic countertransference disposition. Analysis and management of countertransference Whatever the psychotherapeutic approach of the therapist, it cannot but help that one be attentive to the countertransference reactions triggered by any particular patient in any particular session. Psychoanalysis and psychoanalytic psychotherapy intensify transference regression by systematic analysis of the defenses against such a development, and, by the same token, countertransference reactions are magnified by the sharp analytic focus on the nature of the patient/therapist relationship enacted at conscious and unconscious levels. Even in supportive and cognitive behavioral treatments that attempt to utilize the positive aspects of the relationship, and to reduce whatever negative aspects evolve, the awareness of one’s changing emotional dispositions to the patient cannot but help the therapist apply his/her technical approach more appropriately and effectively. In psychoanalytic psychotherapy and psychoanalysis, systematic countertransference analysis is part of the technical approach. It plays a less crucial role in the standard psychoanalysis of patients with neurotic personality organization and the less severe personality disorders than in sicker patients where countertransference, as mentioned before, is activated rapidly, intensively, and dominates the treatment throughout. While with less severely regressed patients the projection of complex, elaborated superego features or attribution of broad attitudinal characteristics to the therapist may keep the countertransference, at least initially, at a relatively low affective level, the typical countertransference with more primitive patients presents more specific, highly individualized, primitive regressive features that correspond to reactivated primitive infantile object relations of the patient, and, hence, can be very useful. Under these circumstances, the therapist may become temporarily enmeshed in a fantastic, primitive emotional experience, reflecting sadistic or masochistic, sexually excited or puritanical, punishing or abandoning, unconscious parental images of the patient or a condensation of various parental representations activated under the impact of a certain emotional attitude. At other moments, the therapist may experience emotions similar to those experienced by the patient but momentarily

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disavowed and now projected onto the therapist, such as intensely dependent, aggressive, sexualized feelings and fantasies, that invade the therapist’s mind in the process of attempting to understand what is going on in the relationship with the patient. In these moments, the therapist’s task is to diagnose the nature of the self and/or object representations activated in himself/herself, in order to include that diagnostic understanding in the forthcoming transference interpretation. A patient with a severe paranoid personality disorder, and a history of extreme prohibitions against any sexual behavior stemming from his fundamentalist religious parents talked in a session about the good understanding he now had with his girlfriend, and how happy he felt about the relationship. For many years he had not been able to be involved in an intimate relationship because of his fears that women with whom he would become sexually engaged would become extremely controlling and manipulative. Because, in the past, he had told me about his fears and reservations about getting involved with his girlfriend sexually, I asked the patient whether there had been any change in their sexual intimacy. The patient looked at me as if astonished by my question. When I tried to find out what brought about this reaction, I became the object of an intense barrage of indignant protests: given the fact that his relationship with this new girlfriend had only lasted a few months, it was absurd, he said, that I should suggest that they should get involved sexually at this point. I had not, of course, suggested that they get involved sexually, and had limited myself to ask about whether there had been any change regarding their relationship. The patient, however, was adamant in insisting that I was trying to push him into a premature sexual relationship which, in his mind, reflected the immorality of the liberal establishment, characteristic of psychotherapists, of which I was a member. It is difficult to convey in a few words the intensity of his attack, but my reaction was one of total impotence in the face of the problematic nature of his reasoning, which he saw as obvious, incontrovertible facts. I had a sense, at this point, that I was forced to identify with the patient’s attacked sexual self, while he was identifying with his puritanical and prohibitive parents. This reflection then permitted me to point out to the patient that what was happening in the session reminded me of his painful feelings of being “brain washed” by his parents, who in his adolescence had been severely disapproving of any manifestation of sexual interests or behavior on his part. What I missed at that point, however, was the fact that the patient responded with a tirade against sexuality in general, when I had asked him whether there had been any change in his “sexual intimacy” with his girlfriend, indicating an inhibition in telling me what his concrete wishes, fears, and prohibitions involved. I thus remained caught up in a deeper level of his defensive operations against sexual fantasies of which I was not aware at that point. Interpretive interventions that include utilization of countertransference understanding require several fundamental preconditions: first, a clear, stable, firm

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boundary of the therapeutic frame to prevent acting out on the part of the patient, and, worst-case scenario, acting out on the part of the therapist with violation of the therapeutic boundaries. The first precondition, therefore, for transference and countertransference analysis is the consistent assurance of the safety of the therapeutic relationship by maintaining a reliably stable frame of the therapeutic situation. A second aspect of the task of countertransference analysis is for the therapist to tolerate the full development of the emotional regression that may occur in his/her mind, the primitive fantasies that may suddenly emerge in his/her mind and sometimes be of a frightening primitivity or crudeness, be it of a passive dependent, masochistic, sadistic, sexually excited or punishing quality. Full tolerance of dependent, aggressive, and sexual fantasies that may emerge in the therapist’s mind is a precondition for his/her raising the question: “Why am I reacting at this point in this way?” “What is it in the patient’s material or in my own disposition that has triggered my reaction to be stimulated in this way?” In other words, the therapist has to tolerate the full experience of his/her emotional reaction in the countertransference without acting on it, and then use it for understanding its origin and meaning. Third, to carry out this task, the therapist has to remain in role. This does not mean that the therapist has to be an indifferent robot or an emotionally nonresponsive human being, but that he/she should maintain the therapeutic stance throughout, regardless of the developments at any particular point, even under conditions of violent affect storms that not infrequently puncture the treatment of borderline patients. To be in role requires a combination of natural, honest behavior, and a controlled, discreet maintenance of strict therapeutic boundaries, which guard against personal disclosure or gratification of personal needs out of countertransference acting out. Fourth, and finally, the introspective analysis of the countertransference, its meaning in terms of the transference situation of the patient, and its elaboration within the interpretation of the total object relationship activated in the transference at this point, is the culminating task of countertransference analysis. In short, maintenance of a therapeutic frame, tolerance of full development of countertransference fantasies and emotions, consistently staying in role, and finally the internal analysis of the meaning of the countertransference to utilize it in the building up of transference interpretations constitute an optimal management of the countertransference. Borderline patients will test the therapeutic limits, and, under the impact of severe regressive conditions, attempt to provoke the therapist, again and again, to cross the boundaries of the therapeutic relationship. In our various research projects we have had experiences of patients who attempted to assault the therapist physically or

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sexually, destroy objects in his office, one patient even divined a therapist’s password and was reading all his email. Under such extreme conditions, the therapist, of course, first has to assure his/her own safety, and the safety of the objects in their office. This safety, and the establishment of conditions for treatment that realistically assure its feasibility, are part of the frame of the treatment, set up in the therapeutic contract at the beginning of the treatment: to maintain this frame becomes the highest priority under the threatening conditions just described. Concern for the safety of the therapist comes before concern for the safety of the patient! In our teaching seminars, we use the metaphor of the airline policy by which adults have to put on their oxygen mask before they put it on the face of small children . . . Even under less extreme conditions, there may be moments in which partial acting out of the countertransference is unavoidable; for example, when a patient, by means of an aggressive act, provokes the therapist to an outburst of anger, or another patient, in an impulsive “strip-tease behavior,” manages to elicit a sexually interested demeanor of the therapist. It is important that the therapist does not deny any momentary loss of appropriate behavior, but rather acknowledges it as calmly as he/she can, and then invites the patient to explore what this reaction on the therapist’s part means to him/her. This approach, which combines the therapist’s honest admission of error with a return to the focus on the transference, will prevent further acting out of his guilt feelings by self revelation, acting out a “guilt trip,” or, to the contrary, vehemently denying a behavior that the patient has clearly observed. The general principle involved implies the need to preserve honesty and, as much as possible, technical neutrality. Particular countertransference complications There are certain treatment situations with patients presenting severe personality disorders that may generate emotional reactions in the therapist that, if not resolved, may end up paralyzing his/her therapeutic efforts. A typical example of such a situation is the case of some severely masochistic patients, involved with a sadistic partner who actually threatens their (the patients’) lives or threatens to blackmail them in a way that would threaten their marriage, social or economic survival. The therapist’s efforts to analyze this masochistic behavior do not seem to lead anywhere; it is as if the patient, unconsciously, were triumphantly asserting his self-destructiveness, projecting his frightened self onto the therapist while professing a blind, fascinated submission to the persecutor in the outside world. At times, the therapist may fear for the patient’s life and feel uncertain about whether to intervene by establishing preconditions for the treatment to continue, or else, under even worse circumstances, suspecting the patient of communicating the content of the therapeutic hours to the persecutor, thus redirecting the hatred and the

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aggression of that object onto the therapist. Under these latter conditions the therapist may fear becoming the victim of a revengeful attack by an antisocial third party. Retrospectively, many of these situations seem a clear case of violation of the therapeutic contract, and, possibly, of the boundaries of the therapeutic situation: but they may develop in surreptitious, gradual fashion that, first, induces an intended countertransference paralysis before the therapist recovers his/her objective stance, only then concerned over the therapeutic frame and for his/her own safety, and recovers his/her freedom to establish firm preconditions for the continuation of the treatment. There are other patients who, without being involved in such extremely dangerous circumstances, develop such an intense hatred in the transference that the therapist becomes afraid of that hatred being transmitted into action. For example, the patient’s spreading false, damaging information about the therapist to third parties, threatening to initiate legal action against the therapist, or a dangerous, aggressive assault on him by the patient. Here, the chronic development of fear and distrust toward the patient leads to the therapist’s secret desire to end the treatment, and intense guilt feelings over such a wished-for abandonment of the patient may paralyze the therapist over time. In these cases, consultation with a trusted senior colleague may be helpful and, eventually, facilitate making decisions regarding the continuation of the treatment, once the safety of the therapist and the boundaries of the therapeutic relationship are assured. With these preconditions in place, testing the patient’s capacity to tolerate the interpretation of the severely aggressive sadomasochistic transference may proceed. Another, less extreme but more frequent complication is the development of the syndrome of arrogance described by Bion (1967), characterized by the patient’s extremely arrogant behavior in the therapy hours, the apparent loss of all capacity for ordinary reasoning or accepting such ordinary reasoning on the part of the therapist, coupled with inordinate curiosity about the therapist and his/her life, that may escalate into spying on the therapist or an attempt to obtain information about him/her from third parties, invading their email communications, etc. Here, the therapist’s realistic hatred in the countertransference may threaten to evolve into projective counteridentification. The key to resolving this development, in addition to maintenance of the therapist’s safety and the frame of the treatment, is the interpretation of the defensive elimination of rational thinking on the part of the patient to avoid the awareness of his/her own hatred. The acting out of the hatred protects against the emotional awareness of it in the transference, particularly against the tolerance of the pleasure that such hatred would give the patient. The interpretation of the defensive function of the acting out of an impulse that could not be tolerated as an emotional experience may gradually transform this acting out into a meaningful resumption of the work in the therapy hours.

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Another type of complication is the complete apparent absence of any emotional relationship with the therapist, typical for some of those with severely narcissistic personality disorders who develop predominately narcissistic defenses in the transference. Under these circumstances, the patient seems to be talking only to himself/herself, with the therapist tolerated as a shadowy witness; or, he/she talks to the therapist in an effort to control the therapist, without really communicating anything about an internal experience. In either case, in spite of an apparent “animation” in the therapy hours, the lack of an emotional relationship may induce a countertransference marked by emptiness and boredom. Boredom, the most typical affect reflecting the absence of a presently significant object relationship, may be an early warning signal before the therapist has even captured the extent of the narcissistic transference. The therapist’s boredom may evolve into distractibility, sleepiness or actually falling asleep, or having to struggle with that impulse in every therapy hour with that particular patient. Here the solution is obviously a systematic analysis of narcissistic defenses: this is one situation where the therapist’s knowledge about the psychopathology and the technical requirements in the psychoanalytic therapy with narcissistic patients may help dramatically and rapidly to resolve this impasse (Kernberg, 1984). Perhaps the most difficult situation to tolerate is that presented by patients who are remarkably “unemotional,” presenting a fac¸ade of polite indifference, and while apparently willing to talk openly about themselves and their difficulties, convey not only a sense of complete hopelessness over their situation, but what may impress the therapist as a cynical rejection of any effort on the therapist’s part to understand the patient and to help by means of understanding. In contrast to patients with a major depression, whose tendency toward negative therapeutic reaction derives from an unconscious sense of not deserving help and who, in effect, may get worse as a reaction to the concerned, helpful attitude of the therapist, the patients I am referring to here are not depressed at all, but present a life trajectory of chronically self-destructive, self-defeating behavior, with a combination of narcissistic grandiosity and superiority, and yet pessimistic self-devaluation. It is as if the main objective in their lives were to destroy any hope and loving attitude presented to them by others. Perhaps the most typical examples of this type are patients who present what Andr´e Green (1993) described as the syndrome of the “dead mother.” These are patients with an intense unconscious tendency to destroy all object relations, as if, by renouncing any human contacts, they could find the happiness of nonexpectations, non-frustration, a kind of psychic death that, unconsciously, signifies their attachment to and identification with the symbolically dead mother. With some frequency, these are also the characteristics of some patients with chronic, severe self-damaging and self-mutilating tendencies, taken to the extreme of loss of

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limbs and/or carefully prepared, calmly desired suicide. These patients may induce a gradually intensifying, unconscious and, eventually, conscious giving up on the part of the therapist, who becomes both victim and unconscious perpetrator of psychic death in the countertransference. Some of these patients can be helped by recovering the traumatic early experiences that are buried underneath their efforts to destroy all significant object relations and, particularly, the therapeutic one. In other cases, the countertransference reaction of internal abandonment may be a realistic indication that, at that point and with that therapist, the treatment has no future. Contemporary controversies regarding countertransference One major issue that divides the psychoanalytic community in their view of the transference/countertransference bind, at this time, is the controversy between a “two person psychology” in opposition to the assumed “one person psychology” of Freud. In my view, the real issue here is insufficient attention to the fact that, in reality, we are always dealing with a “three person psychology,” as has been stressed particularly in the French psychoanalytic literature (De Mijolla and De Mijolla, 1996). Those who have proposed a “two person psychology” criticize Freud for his having focused exclusively on what was going on inside the patient’s mind, rather than on the interaction between patient and analyst, to which the analyst also contributes with his countertransference. Analytic treatment, from that perspective, is the analysis of the bi-personal or intersubjective field, contributed to by both patient and analyst. The Relational Analytic School, Self Psychology, and the Intersubjective Approach all stress this “two person psychology” (Kernberg, 2004b). Within this approach, the patient’s experience in the therapeutic situation is considered almost as symmetrical to that of the analyst’s experience of the situation, in terms of the construction of the meaning of transference and countertransference. Transference, from this viewpoint, is considered in part as a reaction to the countertransference, in parallel to countertransference being a reaction to the transference. This approach highlights the importance of the analysis of the countertransference, and also is linked, in the view of some of the proponents of this approach, to the tendency to communicate the countertransference to the patient under certain circumstances. The alternative position, reflected in what may be considered the psychoanalytic mainstream, constituted by the growing confluence of the British schools (the Kleinian as well as the Independent British approaches), American Ego psychology, and also sustained by the French psychoanalytic school, is that we must assume a “three person psychology.” The implication is that the analyst, in making the analysis of countertransference part of his technical task, is split between one part of

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him/her that, under the effect of countertransference, contributes to the transference /countertransference bind of the analytic situation, while another part of his/her mind, an “excluded third party,” would analyze this total situation as an aspect of the analyst’s interpretive clarification and resolution of the transference. This view corresponds to my own approach, and is consistent with the analysis of countertransference presented in this chapter. I believe that the communication of the countertransference, a derivative of the relationist or interpersonal approaches, undoubtedly helps at times to reassure the patient against feared fantasies, strengthens the reality aspects of the therapeutic situation, and, particularly, reduces the impact of negative transference developments. At the same time, however, communication of the countertransference may drive deeper aspects of the negative transference underground, and maintain the dissociative or splitting processes that are so typical of patients with severe personality disorders. In these cases, communication of the countertransference may correspond to a strong pull toward action in the therapist reflecting intense countertransference activation, and move the treatment into a more reality oriented, supportive approach. This may improve behavioral aspects of the patient’s psychopathology in the short term, but, in the long run, militates against the understanding of deeper aspects of the patient’s unconscious mind. This reduces, I believe, the possibility of obtaining significant characterologic change, and resolution of the underlying personality disorder. I have already mentioned that if a partial acting out of the countertransference occurs, in the sense that there is an actual behavior by the therapist that implies that he/she has abandoned the position of technical neutrality (that is, of the concerned objectivity toward the patient), and the patient is aware of that inappropriate or changed behavior of the therapist, the therapist should acknowledge that observation, and not deny it. However, I reiterate that the therapist should not go any further, in stating what the nature of his/her countertransference problems are. The therapist may acknowledge that he/she has been concerned with personal issues, that he/she may temporarily not have done full justice to the patient’s needs and is aware of the responsibility, to either being able to resolve these internal issues to an extent that would not influence the relationship with the patient, or, should that not be possible, to interrupt, for this session or for the time necessary, the treatment of this patient. Again, I believe that such an honest statement is important, yet protects the patient from being overloaded with the therapist’s problems, and preserves the possibility of a full analysis of the transference, that, in my view, would be lost under conditions of communication of the countertransference. There may be extremely difficult life situations on the therapist’s part that may interfere with his/her work,

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but, insofar as our work uses our own psychic responsivity to our patients, we owe it to them to treat them only when our analytic instrument permits us to do so. Searles (1979) has stressed that it is unavoidable that unresolved issues of the analyst’s personality be activated as part of his/her countertransference reaction. For example, the analyst’s conflicts over sadism and fragmentation, over guilt and concern, may be triggered under circumstances when the patient’s fears in the transference activate his/her sense of not being able to help the fragmented parent to deal with the patient’s guilt over his/her sadism in punishing the parent with his/her illness, and with the patient’s grief over not being able to establish a bond of love with his/her parent. Under such conditions, the tolerance of the analyst’s own unresolved conflicts in the countertransference are a precondition for the therapeutic symbiosis, in which mutual humanization, tolerance, and the acceptance of the identity of the other and of a new bond with the other may take place. The fact that, even under ordinary circumstances, such developments may occur in the countertransference makes the need for the analyst’s capacity to split himself/herself into an experiencing and an observing part so important. Adler (1985) refers to the countertransference to the devaluing borderline patient, from what may be considered a Kohutian perspective, in the sense of an indication for the therapist to explore the patient’s enactment of the relationship with a self object by whom the patient is not sufficiently “mirrored.” The patient is unable to accept the competence of the analyst, whose behavior profoundly threatens the patient’s self assurance. There are serious risks, Adler states, of countertransference acting out under such conditions, and the analyst has to explore to what extent he/she may have contributed to fail the patient as a self object, carrying out insufficient mirroring in response to excessive demands, or to the frustration of the analyst’s own needs. Adler proposes that the analyst explore his/her countertransference from that viewpoint, but not to communicate it to the patient. Another controversial countertransference issue – less frequently debated, but implicitly present, particularly with patients who, as part their psychopathology, show profound deviation from habitual social behavior, anti-social tendencies, or esoteric and strange lifestyles – involves the extent to which the therapist should and may be able to maintain a position of concerned objectivity; that is, of technical neutrality, rather than attempting to influence the patients with his/her own value systems. It has been said that the therapist should be moral without being moralistic (Ticho, 1972), and that he should make a concerted and consistent effort to let the patient evolve his/her own ideological choices and commitments. I think we have to accept the limits of the position of technical neutrality insofar as it may be more dependent on cultural norms jointly adhered to by patient and therapist than what we are usually aware of. The changing view, within the psychiatric and

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psychoanalytic community on homosexuality, for example, illustrates how socially prevalent beliefs may influence assumedly scientific thinking and attitudes toward patients: with this word of caution I conclude this review of countertransference.

R EF EREN CES Adler, G. (1985). Devaluation and countertransference. In Borderline Psychopathology and its Treatment, Vol. 10. New York: Jason Aronson, pp. 171–188. ´ anal´ıtica como campo din´amico. Rev Baranger, M. and Baranger, W. (1961–62). La situacion Uruguaya Psicoan IV(1): 3–54. Baranger, M. and Baranger, W. (1969). Problemas del Campo Psicoanalitico. Buenos Aires: Kargieman. Baranger, M., Baranger, W. and Mom, J. (1982). Proceso y no proceso en el trabajo anal´ıtico. Rev Psicoan 39: 527–549. English translation in Int J Psychoanal 1983; 64: 1–15. Bion, W. R. (1967). On arrogance. In Second Thoughts: Selected Papers on Psychoanalysis. New York: Basic Books, pp. 86–92. Clarkin, J. F., Yeomans, F. and Kernberg, O. F. (1999). Treatment of Borderline Personality. New York: Wiley. De Mijolla, A. and De Mijolla, M. S. (1996). Psychanalyse. Paris: Presses Universitaires de France. Freud, A. (1936). The Ego and the Mechanisms of Defense. The Writings of Anna Freud, Vol. 2. New York: International Universities Press, 1993. Freud, S. (1910). The Future Prospects of Psycho-Analytic Therapy: Standard Edition, Vol. 11, pp. 139–151. London: Hogarth Press, 1957. Green, A. (1993). On Private Madness. Madison, CN: International Universities Press. Grinberg, L. (1956). Sobre algunos problemas de t´ecnica psicoanal`ıtica determinados por la ´ y contraidentificacion ´ proyectivas. Rev Psicoan 13: 507–511. identificacion Grinberg, L. (1979). Projective counteridentification and countertransference. In L. Epstein and A. Feiner. (eds.) Countertransference. New York: Jason Aronson, pp. 169–192. Heimann, P. (1950). On countertransference. Int J Psychoanal 31: 81–84. Kernberg, O. (1975). Borderline Conditions and Pathological Narcissism. New Jersey: Jason Aronson. Kernberg, O. (1976). Object Relations Theory and Clinical Psycho-Analysis. New York: Jason Aronson. Kernberg, O. (1984). Severe Personality Disorders. New Haven: Yale University Press, pp. 197–209. Kernberg, O. (1999). Psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy: contemporary controversies. Int J Psychoanal 80(6): 1075–1091. Kernberg, O. (2004a). Aggressivity, Narcissism, and Self-Destructiveness in the Psychotherapeutic Relationship. New Haven: Yale University Press, pp. 167–183. Kernberg, O. (2004b). Contemporary Controversies in Psychoanalytic Theory, Techniques, and Their Applications. New Haven: Yale University Press, pp. 285–304. Racker, H. (1957). The meaning and uses of countertransference. Psychoanal Q 26: 303–357.

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Otto F. Kernberg Sandler, J. (1976). Countertransference and role-responsiveness. Int Rev Psychoanal 3: 43–47. Searles, H. F. (1979). Countertransference and theoretical model. In Countertransference and Related Subjects: Selected Papers, Vol. 18. New York: International Universities Press, pp. 373– 379. Ticho, E. (1972). The effects of the psychoanalyst’s personality on the treatment. In J. A. Lindon (ed.) Psychoanalytic Forum, Vol. 4. New York: International Universities Press, pp. 137–151. Tower, L. E. (1956). Countertransference. J Am Psychoanal Assoc 4: 224–255.

4 4

Beyond management to cure: enhancing the positive dimensions of personality C. Robert Cloninger

Introduction Individuals with severe personality disorders have little or no awareness of the satisfactions of life that are derived from an outlook of unity and connectedness with other people and nature. Their lack of awareness of the meaningful connections among all things is rooted in an outlook of separateness and fear, which leads to their self-defeating and often self-destructive thoughts, feelings, and actions. In this chapter on the future of work with patients with severe personality disorders, I will describe empirical findings about the path to well-being by which human character and self-awareness develops. I will also describe tools that are needed for the facilitation of growth in character, self-awareness, and well-being at each step along the path to happiness. This model of character development is supported empirically by both longitudinal studies of character development and findings from several randomized controlled trials about what is effective in psychotherapy. These empirical findings set the stage for acknowledgement of the many obstacles that can emerge in the treatment of patients with severe personality disorders, so that they can be understood within a general theoretical framework. In this way, the stage for future progress can be well grounded in the scientific tradition of hypotheticaldeductive research and guided by the wisdom of experienced clinicians, such as those who have contributed to this book. Mental health professionals and their patients are increasingly aware of the basic need of all human beings for meaning that is greater than one’s self. The growth in awareness is mostly driven by the professional’s practical goal of reducing disability from mental disorders and by the heart-felt wishes of the suffering for their therapists to help them to be happier. As a result, mental health professionals and the general public are growing in awareness of the need to foster growth in well-being in clinical practice. Patients with severe personality disorders rarely ask for help to  C Cambridge University Press 2007

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grow in awareness, if they ask for help at all. Nevertheless, the desire to be happy and have relief from the pains of emptiness, abuse, and shame can only be satisfied by personal work that will lead to the development of character and well-being. Fortunately, there is currently a groundswell of professional work that focuses on the development of health and happiness, rather than merely fighting disease and distress (Cloninger, 2004). I believe that the future of work on severe personality disorders is to reorganize the therapeutic perspective to focus on ways to facilitate the development of well-being, which is characterized by positive emotions, mature character configurations, satisfaction with life, and virtuous conduct. The stage is usually set for well-being by a childhood that provides the positive experiences producing an outlook on life leading to expectations of happiness, connectedness, and meaning. By finding enjoyment and value in life, a person then proceeds to regulate their emotions, thoughts, and actions to maintain happiness in ways that are mature and stable. Only the prior experience of satisfaction with life provides the awareness and motivation to do the challenging work of facing life as a self-reliant and tolerant young adult. Even later in life, adults recognize that their aging, sicknesses, and problems provide additional experiences that help them to learn to find meaning beyond their individual self. Each of these three major phases of life contributes to the full development of well-being. Likewise, the effectiveness of the therapeutic process is incomplete when we focus largely on the tasks and skills of the cognitive middle-phase of life while neglecting the early phase of supportive nurturing of pleasant experiences or the late phase of self-transcendence in the face of death and human frailty. I recognize that patients with severe personality disorders usually begin their life with many adverse childhood experiences. I also recognize that the distinctive features of well-being are exactly what patients with severe personality disorders are lacking. I also recognize that patients with severe personality disorders want positive emotions and relief from negative emotions, but do not realize that these experiences require the development of awareness of meaning and values beyond their immediate desires. The challenge of therapeutic dialog is to know how to engage them in doing the work that will lead to well-being, even though they do not begin with much insight into what well-being is in reality. In order to understand how to facilitate the development of well-being, we can learn much from other work on the treatment of recurrent depression, which is part of the clinical picture of patients with severe personality disorders. The practical necessity to reduce disability Major depression is the leading cause of disability (measured as the number of years lived with a disabling condition) among persons aged 5 and older (Murray

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and Lopez, 1996). Major depression alone results in the average loss worldwide of more than 6 years of healthy life per person. Alcohol use, drug use, and other mental disorders bring the total burden to over 20 years. It is ironic that personality disorders are not explicitly listed as the cause of these mental disabilities. In fact, personality disorder, or at least issues that can best be understood in terms of problems in emotional regulation and character development, may be the underlying cause of most, if not all, mental disorders. The treatment of mental disorders has been improved with the introduction of many medications and psychotherapy techniques that show acute benefits in randomized controlled trials. However, the benefits of these medications are moderate and incomplete, so that there is frequent drop-out, relapse, and recurrence of illness. Although pharmacotherapy is largely passive, it does require some motivation and adherence, which is often poor in patients with severe personality disorders precisely because they fail to recognize much value in life. Even in the treatment of major depression, the acute response to antidepressants or cognitive behavioral therapy is only moderate. Substantial improvement occurs in about 50%–65% of patients receiving active treatment, compared to 30%–45% in control subjects (Walsh et al., 2002). Relapse is rapid in subjects who drop-out or prematurely discontinue treatment because there is no correction of the underlying causes of the disorder. Most patients with major depression who do improve acutely have recurrences within the next 3 years despite use of medications and cognitive behavioral therapy (CBT) (Fava et al., 1998a,b). The outcomes are likewise inadequate from available treatments for other disorders, such as schizophrenia, bipolar disorder, anxiety disorders, alcohol and drug dependence. For example, 74% of patients with schizophrenia discontinued the antipsychotic they were prescribed before 18 months in a recent trial comparing available second-generation (atypical) neuroleptics to the first-generation (typical) drug perphenazine (Lieberman et al., 2005). All available drugs were discontinued with nearly equal frequency because of high rates of non-response, intolerable side-effects, and non-adherence. The inadequacy of available treatments results in persistent residual symptoms of disease and distress, as well as low levels of life satisfaction and well-being, in most patients with mental disorders. The absence of life satisfaction and positive emotions is a serious problem because the absence of positive emotions is more predictive of subsequent mortality and morbidity than the presence of negative emotions (Danner et al., 2001; Huppert and Whittington, 2003). The presence of positive emotions in early life is strongly predictive of longevity (Danner et al., 2001). As a result, people with adverse childhood experiences, as is often the case in severe personality disorders, often have the lives they expect – short, mean, and unhappy. Unfortunately, there has been no improvement whatsoever in the average levels of life satisfaction in the general population as a result of improvements in child

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and adult psychiatry, such as the introduction of psychotropic drugs or manualized forms of psychotherapy from 1950 to the present time (Myers and Diener, 1996). What does reduce disability and enhance well-being? Fortunately, recent work on well-being has shown that it is possible to improve well-being and reduce disability in the general population, and in most, if not all, mental disorders (Cloninger, 2004; D’Souza and Rodrigo, 2004; Fava et al., 1998a, 1998b, 2005; Seligman, 2002). The effective methods of intervention focus on the development of positive emotions and the character traits that underlie well-being, as has been described in positive approaches to philosophies of life, psychology, and psychiatry (Cloninger, 2004). Randomized controlled trials of therapies to enhance well-being in patients with mental disorders show improvements in happiness and character strengths that improve treatment adherence and relapse and recurrence rates when compared to CBT or psychotropic medication alone (Fava et al., 1998a, 1998b, 2005). Randomized controlled trials to enhance well-being are also effective in samples of students and volunteers from the general population (Emmons and McCullough, 2003; Seligman, 2002). The methods of improving well-being can be understood as working on the development of the three branches of mental self-government that can be measured as character traits in the Temperament and Character Inventory (TCI) (Cloninger et al., 1993, 1997). The three TCI character traits are called Self-directedness (i.e., responsible, purposeful, and resourceful), Cooperativeness (i.e., tolerant, helpful, compassionate), and Self-transcendence (i.e., intuitive, judicious, spiritual). In essence, high scorers in all three of these character traits have frequent positive emotions (i.e., happy, joyful, satisfied, optimistic) and infrequent negative emotions (i.e., anxious, sad, angry, pessimistic). These character traits can be exercised and developed by interventions that encourage a sense of acceptance, hope, and mastery for Self-directedness, an attitude of tolerance, kindness and forgiveness for Cooperativeness, and the experience of awareness, commitment, and meaning greater than oneself for Self-transcendence. Low TCI Self-directedness is the fundamental characteristic of personality disorders in general (Cloninger et al., 1993, 1997), and is also a strong indicator of vulnerability to major depressive disorders when combined with high Harm Avoidance (i.e., shy, pessimistic, fearful, and fatigable) (Farmer et al., 2003). In particular, low TCI Self-directedness is what distinguishes individuals with severe personality disorders from all others, including milder personality disorders who may be fairly selfdirected but are uncooperative (i.e., low in Cooperativeness) or self-centered and controlling (i.e., low in Self-transcendence) (Cloninger et al., 1993, 1997; Svrakic et al., 1993). High scores in TCI Self-directedness are predictive of a rapid and

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stable response to both antidepressants (Cloninger, 2000; Tome et al., 1997) and CBT (Bulik et al., 1998). Skills training and encouragement of problem solving lead to increases in autonomy and the sense of personal mastery, which all facilitate greater hope and well-being in ways that are common in effective psychotherapies, including CBT (Beck, 1996; Beck and Freeman, 1990; Burns, 1980), Dialectic Behavior Therapy (DBT) (Linehan, 1993), or CBT augmented with modules for awareness of positive emotions (Fava et al., 1998a, 1998b, 2005), mindfulness (Teasdale et al., 2000, 2002), acceptance and commitment (Hayes et al., 1999) or spiritual meaning (Burns, 1980; D’Souza and Rodrigo, 2004; Fava et al., 1998a,b). However, the addition of modules for cultivating positive emotions, mindfulness, and/or meaning and commitment reduces drop-outs, relapse, and recurrence rates substantially when compared to cognitive behavioral approaches alone. For example, the finding of spiritual meaning through self-transcendent values reduces relapse and improves well-being in randomized controlled trials of patients with depression, schizophrenia, and terminal diseases (D’Souza and Rodrigo, 2004). Likewise, in the treatment of patients with recurrent depression, additional work on positive emotions lowered relapse and recurrence rates in 40 recurrent depressives over 2 years (25% versus 80%) (Fava et al., 1998a,b). Mindfulness training reduced the relapses from 78% to 36% at 60 weeks in 200 depressives with three or more episodes in two studies (Ma and Teasdale, 2004; Teasdale et al., 2000, 2002). Of course, these findings about relapse prevention in recurrent depression are directly relevant to understanding severe personality disorders for three reasons. First, the patients with recurrent depression often have an adolescent onset of negative moods, an underlying personality disorder, and associated histories of adverse childhood experiences (Teasdale et al., 2000). Second, the reduction in relapse is achieved by reductions in dichotomous thinking (Teasdale et al., 2002), which is a prominent clinical feature in patients with severe personality disorders (Cloninger and Svrakic, 2000). Third, the dysfunctional thinking characteristic of severe personality disorders is strongly correlated with low TCI Self-directedness (Luty et al., 1999), and both low Self-directedness and dysfunctional attitudes are related to a deficit in meta-cognitive awareness (Cloninger, 2004; Sheppard and Teasdale, 2000). Improvements in each of these areas is beneficial, but emotional consistency and resilience depend on the balanced development of all three major dimensions of character (Cloninger, 2004; Cloninger et al., 1993, 1997). Not all methods that use mindfulness, for example, increase well-being. For example, Linehan’s DBT for patients with severe personality disorders uses behavioral and mindfulness techniques that reduce rates of suicide attempts and hospitalization, but has not been shown to reduce feelings of hopelessness and emptiness (Linehan, 1993). It is

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unclear whether the persistent hopeless thinking observed with DBT is the result of the severity of the underlying personality disorder, the outlook of separateness and alienation present in some DBT materials (Linehan, 1993) (such as validating patients’ status as victims who are poorly treated by physicians), or other factors implicit in its strict behaviorist perspective that can undermine the development of well-being through meta-cognitive awareness and character development. Western concepts of mental health usually emphasize Self-directedness and Cooperativeness, but neglect the crucial role of spiritual awareness and meaning based on self-transcendent values. In order to understand the importance of Self-transcendence for well-being, I will now consider patients’ demand for professional recognition of the human need for spiritual meaning – that is, meaning greater than one’s individual self. The wishes of the suffering for spiritual meaning Most psychiatric patients want their therapist to be aware of their spiritual beliefs and needs because human spirituality has an essential role in coping with challenges and enjoying life (D’Souza and Rodrigo, 2004). In fact, the word psychiatry is derived from Greek and literally means “the healing of the psyche.” The “psyche” is the Greek word for soul or spirit, which is the immaterial but intelligent aspect of the consciousness of a human being. Human consciousness is characterized by a capacity for self-awareness, creative gifts that are innate but neither inherited nor acquired, and free choices that are not fully determined by past experience (Cloninger, 2004). The great mystery of neuroscience is that human consciousness cannot be explained or reduced to materialistic processes (Chalmers, 1996; Kandel et al., 2000). As a result of the fact that human consciousness transcends materialistic explanations, psychiatry now finds itself at an important crossroad. The fostering of spirituality and well-being is crucial for psychiatry to achieve its meaning and purpose, but spirituality and well-being have been neglected because of a tendency toward materialistic reductionism. Psychiatry is at this crossroad, at which it has the opportunity to recognize a broader understanding of what it means to be a human being. Humanity cannot be reduced to matter, as in behaviorism or molecular psychiatry. Humanity also cannot be reduced to the dualism of body and mind, as in cognitive behavioral or psychoanalytic approaches that neglect Self-transcendence (even if they include mindfulness training). Self-awareness requires an understanding of the physical, mental, and spiritual aspects of a human being. To foster fuller self-awareness, cognitive behavioral and psychodynamic therapies can be augmented with an added focus on existential issues, such as finding self-acceptance and meaning in coping with life challenges.

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Meaning can be found by encountering someone or something that is valued, acting with kindness and purpose in the service of others, or developing attitudes such as compassion and humor that give meaning to suffering (D’Souza and Rodrigo, 2004; Frankl, 1959, 1978). Spiritually augmented therapy is more effective than CBT in activating feelings of hope and life satisfaction (D’Souza and Rodrigo, 2004; Frankl, 1959, 1978). It is also shown in randomized controlled trials to reduce relapse rates and enhance the quality of functional recovery (D’Souza and Rodrigo, 2004). The reduction in relapse rates suggests that fostering the search for meaning may sometimes help people to develop their character to new levels, which reduces their vulnerability to future episodes. However, what has been described as spiritually augmented therapy in the past has not usually produced radical personality change because it has been designed primarily for acute intervention for depression and demoralization in people who already find strength in their religion, in meditation, or other approaches to spirituality. In order to incorporate a fuller understanding of spiritual development into general clinical practice, it is necessary to understand the way that people normally develop their sense of well-being. Well-being can be defined in different ways, such as subjective satisfaction with life, positive emotions, virtuous living, or coherence of personality (Cloninger, 2004). Fortunately, these alternative definitions all converge: people who have coherent personalities, defined in terms of mature character traits, are also wise, virtuous, and well-satisfied with their life because they have frequent positive emotions and infrequent negative emotions (Cloninger, 2004). As a result, fostering the development of character traits, such as being self-directed, cooperative, and spiritual, automatically leads to a good quality of life. Understanding the ways to foster spiritual development allows a therapist to treat the full range of psychopathology, provided the therapist knows appropriate ways of dealing with the many obstacles that patients may encounter along the path to well-being. In this chapter on the future of work on severe personality disorders, I will summarize briefly work about the science of well-being, including the stages by which self-awareness and well-being develop, the associated character traits, and the activities and experiences that foster the development of spirituality and well-being. A more detailed account is given elsewhere (Cloninger, 2004). The general practice of psychiatry requires an understanding of a catalytic sequence of interventions that allows patients to acquire a solid foundation of awareness that clarifies who they are and what gives life meaning and satisfaction. Psychiatrists need tools that work in individuals with severe personality disorders who have little sense that life can be meaningful or satisfying or who lack energy and motivation to do much work in therapy. Otherwise the range of application is limited or the therapist is doing all the work, which is inevitably unproductive and frustrating.

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C. Robert Cloninger Table 4.1 Three stages of self-awareness on the path to well-being

Stage

Description

Psychological characteristics

0

Unaware

1

Average adult cognition

2

Meta-cognition

3

Contemplation

Immature, seeking immediate gratification (“child-like” ego-state) Purposeful but egocentric, able to delay gratification, but has frequent negative emotions (anxiety, anger, disgust) (“adult” ego-state) Mature and allocentric, aware of own subconscious thinking, calm and patient, so able to supervise conflicts and relationships (“parental” ego-state) Effortless calm, impartial awareness, wise, creative, and loving, able to access what was previously unconscious as needed without effort or distress (“state of well-being”)

Psychiatrists also need access to resources that help them deliver meaningful therapy to patients efficiently. Psychiatrists need information to supplement their education and understanding of spiritual development as a biopsychosocial process that is not dogmatic or sectarian. Authentic development of well-being requires respect for the autonomy of others and tolerance for divergent opinions. Accordingly, I will summarize key concepts and findings about the science of well-being, and encourage interested readers to consult fuller accounts elsewhere (Cloninger, 2004, 2007). Stages in the path to well-being There are three major stages of self-awareness along the path to well-being, as summarized in Table 4.1, based on extensive work by many people (Cloninger, 2004). The absence of self-awareness occurs in severe personality disorders and psychoses in which there is little or no insightful awareness of the preverbal outlook or beliefs and interpretations that automatically lead to emotional drives and actions. Lacking self-awareness, people act on their immediate likes and dislikes, which is usually described as an immature or “child-like” ego state. The first stage of self-awareness is typical of most adults today. Ordinary adult cognition involves a capacity to delay gratification in order to attain personal goals, but remains egocentric with frequent distress when attachments are lost or desires are frustrated. Hence the average person can function well under good conditions, but may frequently experience problems under stress. At this stage a person is able to make a choice to relax and let go of their negative emotions, thereby setting the stage for acceptance of reality and movement to higher stages of coherent understanding.

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The second stage of self-aware consciousness is typical of adults when they operate like a “good parent.” A good parent is allocentric in perspective – that is, they are “other-centered” and capable of calmly considering the perspective and needs of their children and other people in a balanced way that leads to satisfaction and harmony. This state is experienced when a person is able to observe their own subconscious thoughts and consider the thought processes of others in a similar way to their observing their own thoughts. Hence the second stage can be described as “meta-cognitive” awareness, mindfulness, or “mentalizing.” The ability of the mind to observe itself facilitates growth in awareness, which in turn leads to more flexibility in action by reducing dichotomous and egocentric thinking (Bateman and Fonagy, 2004; Teasdale et al., 2002). At this stage, a person is able to observe himor herself and others for understanding, without judging or blaming. A substantial minority of people achieve this second stage of self-awareness in their maximum thoughts under good conditions, but most people do not experience this without special training (Cloninger, 2005). The third stage of self-awareness is called contemplation because it is direct perception of one’s initial perspective – that is, the preverbal outlook or schemas that direct one’s attention and provide the frame of reference that organizes a person’s expectations, attitudes, and interpretation of life events. Direct awareness of our outlook allows the enlarging of consciousness by accessing previously unconscious material, thereby letting go of wishful thinking, unfounded expectations, and facilitating the impartial questioning of basic assumptions and core beliefs about life, such as “I am helpless,” “I am unlovable,” or “faith is an illusion.” Unfortunately, the third stage of self-awareness is only rarely experienced without special training in meditation and contemplation (Cloninger, 2004). Extensive empirical work has shown that movement through these stages of development can be described and quantified in terms of steps in character development or psychosocial development, as in the work of Vaillant on Erikson’s stages of ego development (Vaillant and Milofsky, 1980). Such development can be visualized as a spiral of expanding height, width, and depth as a person matures or increases in coherence of personality. The dimensions of the spiral can be quantified in terms of the degree to which a person is self-directed (visualized as the height of the spiral or the degree to which a person’s outlook integrates reason and love in action), cooperative (visualized as the width of the spiral or the degree of social concern and love), and self-transcendent (visualized as the depth of the spiral or degree of intuitive insight and awareness) (Cloninger, 2004). Likewise, the movement of thought from week to week or month to month has the same spiral form regardless of the time scale. Such “self-similarity” in form regardless of time scale is a property characteristic of complex adaptive systems, which are typical of neurobiological and psychosocial processes in general (Cloninger, 2004). The

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clinical utility of similarity in form regardless of time scale is that therapists can teach people to exercise their capacity for self-awareness, moving through each of the stages of awareness just described. Their ability to do so, and the difficulties they have, reveals on mental status examination the way they are able to face challenges in life from day to day. I have developed an exercise, called the “Silence of the Mind” meditation, with explicit instructions to take people through each of the stages of awareness as well as they can (Cloninger, 2004) (see pages 84–95 of Feeling Good). Using this and a way of observing thought during mental status examination, mental health professionals can assess a person’s thought and its level of coherence in a way that is constructive, easy, and precise without being judgmental. Based on studies of stages in character development and emotional consistency, I have also developed a psychotherapy program that involves a catalytic sequence of 15 intervention modules to guide a person along the path to well-being. These are described in terms of an explicit script in my therapeutic dialog with a patient who has poor past character development but is going through therapy to become more healthy and happy. This therapeutic sequence corresponds to the natural sequence by which a person grows in self-awareness, adapted to provide therapeutic guidance and self-help exercises in a way that will lead to systematic progress toward well-being. Each of the 15 modules or therapeutic sessions is being recorded for production as a DVD series, along with a book to assist therapists in using it as an adjunct to their treatment (Cloninger, 2007). In this way, the DVD series, which is called “The Happy Life – Voyages to Well-Being,” provides the patient with guidance in a standardized and enjoyable format, which they can watch and practice at home or in a doctor’s office. Each module is about 40 min of dialog, suitable for use in a self-help format or as an adjunct to individual or group therapy. It is designed as a universal intervention that can be enjoyed by anyone regardless of his or her level of physical and mental health as long as they have the reading comprehension of an average 14 year old. The therapist does not have to repeat instructions or go through standard material, but is free to discuss individualized issues with the patient and suggest applications and homework that is especially appropriate to their particular situation. The pacing of intervals between modules in the series can be determined by the motivation and situation of the patient, and orchestrated by the therapist. It can also be used for self-help. I will briefly describe the sequence, which is designed so that successive modules build on and extend what has been previously learned and practiced. Voyages to well-being The full series consists of 3 sets of 5 modules, creating a total of 15 modules. The first set is called “Awakening,” the second “Illumination,” and the third “Integrated

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Enhancing positive dimensions of personality for cure Table 4.2 Titles and Topics of the 15 modules of “Voyages to Well-Being”

Set I

– Module 1: What Makes You Happy? – Recognizing What Brings Joy – Module 2: What Makes You Unhappy? – Understanding Traps in Thinking – Module 3: Experiencing Well-Being – Quieting the Mind’s Turmoil – Module 4: Union in Nature – Awakening Your Physical Senses – Module 5: Finding Meaning – Awakening Your Spiritual Senses

Set II

– Module 6: Can Your Average Day Be Filled with Happiness? – Module 7: Observing and Elevating Your Thoughts – Module 8: Observing and Elevating Your Human Relationships – Module 9: Charting Your Maturity and Integration – Module 10: Contemplation of Being

Set III

– Module 11: Can You Learn to Reduce Stress? – Seeing the Sources of Problems – Module 12: Observing and Quieting Your Fears – Module 13: Observing the Power-Seekers in Your Life – Module 14: Contemplation of Mysteries – Module 15: Constant Awareness

Intelligence.” The names and topics of the modules are listed in Table 4.2. The following text describes the modules as they are briefly described in the first module, as a sample of my explanations using non-technical phrasing such as I use with my patients in clinical practice and in teaching clinical workshops with people from a wide range of experience in doing psychotherapy. The first set of five DVDs is called “Awakening” because it can help you to recognize what brings you happiness. That is the goal of the first set – to become clear about and aware of what makes you happy. You need to experience directly for yourself what you find satisfying and joyful. This awakening is like the benefits of a happy childhood – awakening to the joys and wonders of life gives us the experiences that motivate work with an attitude of hope on the problems and challenges we also face. Before you can have hope you first need to have something you positively value. The first set shows you how to experience joy and satisfaction by awakening your awareness of your body, your mind, and your spirit. Each DVD gives you exercises to practice so that you may actually experience joy. The only way to know joy or beauty is to experience it in your life. For example, you cannot know how delicious a strawberry is without tasting it yourself. The second set of DVDs helps you learn to be happy most of the time, not just occasionally. In order to be happy most of the time, we have to learn how to regulate our emotions and achieve goals in a way that is stable and consistent, like a good parent. It’s called “Illumination” because joy is like a light that can shine on you like the summer sun. Once you are clear and aware about what experiences make you happy, then you will want to fill your daily life with those moments. You will want to nourish your hope with love to be happy consistently. Remember that we all have good moments and bad moments, good days and bad days. In other words, our thoughts have a wide range of states. The highest point of our thoughts, their

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C. Robert Cloninger maximum, is our peak experience of joy and happiness; it’s like how we feel on a really good day. The average of our thoughts is the way we usually think and feel in a wide variety of situations. The lowest point of our thoughts, their minimum, is the way we feel under stress on a very bad day. In the first set of modules you will learn how to elevate your maximum thoughts and feelings to be happy under good conditions. In the second set of modules, you will learn to raise your average thoughts by having good moments more frequently and bad moments less frequently. You will practice regulating your emotions and organizing your life in a way that is stable and productive, like someone who is a productive worker, a considerate friend, and a good parent. The motivation is to do what you really want – to be happy consistently. The third set of modules is called “Integrated Intelligence.” We all have fears and sensitivities that cause us problems. We all have questions about what gives meaning and value to our existence. Certain situations or people can exert powerful influences on us, acting in ways that hurt us. To understand these stresses, we have to see beyond our past conditioning and traditions, to recognize what we truly value – what gives our life its true meaning. The third set of modules helps us learn to recognize and understand the internal and external influences that stress us or distract us from what we value the most. We can learn ways to recognize these influences and thereby reduce their power over us. We can learn to recognize the non-verbal symbols used by our own unconscious, as well as external influences on our subconscious, much like we observe in dreams and some kinds of advertising. By recognizing and understanding these influences, we can let what is good within us express itself. In that way, we can learn to live so that our goals and values are well-integrated. The third set is called “Integrated Intelligence” because it helps us to let go of our conflicts and to express the love and intelligence that is within each of us. We practice ways to be more aware so that our life is filled with meaning in a way that is inspired and guided by our most deeply felt values. By following our true path with equal respect for the dignity of our self and others, our outlook on life is no longer divided by fears, prejudice, and doubt. Then, our life takes on a value and meaning greater than our individual self, like someone who is wise, unselfish, and very happy. (Reprinted with permission of copyright holder, C. Robert Cloninger, 2005)

These three sets of voyages parallel the stages of our natural development in life. Under conditions that allow us to flourish, we first have a childhood filled with serenity and experiences that expose us to kindness and joy. Many people don’t have such a happy start in life, but nearly everyone has the potential to learn to be happy. Then as we become more independent as young adults, we grow in our ability to regulate our own life and circumstances to be happy consistently, as in our second set of voyages. Finally, as we age past our physical and intellectual peak, we must question what we value and what gives our life dignity and meaning. This is crucial to prepare ourselves to face what we cannot control, for example death and losses, with dignity and serenity. Each of these three major stages of life builds on the other and reflects the natural development of our body, mind, and spirit throughout life. It works much better to do what is natural than to try to skip a stage without building the proper foundation for the work of the future. For example, the benefits of behavioral and cognitive therapies may be reduced if they skip the

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awakening phase needed to increase the recognition of the joys of life. Likewise, the benefits of psychoanalytic therapies may be reduced if they skip both the awakening and illuminative phases of therapy, reducing its effectiveness to individuals who are already relatively mature and psychologically minded. Besides, it is more enjoyable, as well as more effective, to do what is natural! All of the techniques have been tested in clinical work and draw on extensive work in many diverse forms of therapy (Cloninger, 2004; Cloninger and Svrakic, 1997). Most of the individual techniques have been tested in previous randomized controlled trials described earlier in this chapter. A randomized controlled trial of the interventions as a complete set is being planned. It is interesting to note that the first set of modules emphasizes behavioral methods focused on positive emotions along with basic concepts of cognitive processing. The second module emphasizes mindfulness regarding subconscious thought processes and increasing meta-cognitive awareness. The third set of modules involves contemplative access to and recognition of the meaning of preverbal symbols by which internal and external influences that are usually unconscious communicate by framing subconscious expectations, as in dreams and some forms of advertising, social movements, and other powerful situations (Cloninger, 2005). These three stages of therapy correspond to the natural stages of character development in life, to stages of self-awareness, and to the stages of spiritual development, and are based on explicit psychobiological principles, as I have described in detail elsewhere (Cloninger, 2004). For example, the behavioral emphasis of the first phase corresponds to the “purgative” or active behavioral phase of spiritual development. The cognitive emphasis of the second phase corresponds to the “illuminative” or passive mindfulness phase of spiritual development. The enlarging of consciousness in the third phase corresponds to the “unitive” or contemplative phase of spiritual development in which there is constant awareness of one’s outlook and participant role in the universal unity of being. It has features of psychoanalytic practice as a result of its focus on what was previously unconscious, but it has a positive attitude toward spirituality and is reserved for use in individuals who would be considered “good” candidates for analysis because they have previously worked through the foundational levels of awareness of the earlier phases. I have found it crucial for both practice and teaching to describe specific interventions in an orderly sequence. Doing so helps me to be more systematic and thorough as a therapist and as a teacher. Hopefully this allows colleagues as well as patients to recognize and understand the goals of each intervention on the processes of thought. Nevertheless, any individual patient presents unique skills and sensitivities that must be recognized for optimal care. It is my hope that an explicit description of a catalytic sequence of interventions will help therapists work with patients throughout the full range of well-being from severe personality disorder to joyful living. It is also my hope that this full set of

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interventions will encourage therapists to overcome their unfortunate reluctance to attend to their patient’s spiritual needs, which is an important aspect of the treatment of severe personality disorders. Religious conversion or spiritual re-birth is regularly reported by individuals with severe personality disorders, including antisocial and borderline personality disorders, who go into remission (Cloninger, 2005; Robins, 1966). Yet psychiatrists are often insensitive and uncomfortable discussing spirituality with their patients (Larson et al., 1993). I have found it possible to be non-judgemental in raising questions about spiritual values for my patients. I emphasize that each person must question all authorities, including me. As a result, I emphasize the importance of providing private exercises by which people can obtain answers for themselves. This allows attention to spirituality based on principles of psychobiology with roots in compassion and tolerance, rather than on the basis of dogmatic judgements that are rooted in fear and intolerance. Obstacles to well-being in patients with severe personality disorders An effective therapeutic intervention requires a working alliance. Even patients with severe personality disorders will work in therapy, but only if they recognize that the therapy is about something that they really want. In fact, the quality of the working alliance largely depends on whether the patient thinks that the therapist listens to what the patient wants to work on and is helping the patient with what they want (Horvath and Greenberg, 1989; Tichener and Hill, 1989). In order to have an effective working alliance, then the patient must have something that they value in life. What is valued, in its most basic hedonic form, is usually the desire to be happy and to avoid pain and suffering. Ultimately, I think it is the desire for happiness and/or relief of emptiness and suffering that motivates patients with severe personality disorders to do therapeutic work. That is why the first set of intervention modules focuses on clarifying what is satisfying and what is not satisfying, and encourages actions that provide positive experiences. Even with basic positive motivations for happiness and relief of emptiness, there are additional obstacles in patients with severe personality disorders, as described by Michael Stone in Chapter 1. A list of major obstacles to psychotherapy in patients with severe personality disorders is given in Table 4.3, which corresponds closely with the list of obstacles documented by Michael Stone earlier in this book. In Table 4.3 I have also indicated the level of coherence of thought according to my quantitative ranking method for the coherence of thought, which is called the Diagnosis of the Frequency of Thought (DFT). A full description of the DFT method is given elsewhere (Cloninger, 2004). It is remarkable that the obstacles to treating severe personality disorders are the manifestations of low self-awareness, as indicated by a low value of the coherence of thought (i.e., a low DFT value), as shown in Table 4.4.

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Enhancing positive dimensions of personality for cure Table 4.3 What are some major obstacles to well-being in patients with severe personality disorders? (for meaning of DFT values, see Table 4.4)

1. 2. 3. 4. 5. 6. 7. 8.

No sense of value of life (emptiness) – DFT 2.0 Poor reality-testing or extreme cognitive distortion – DFT 2.0–2.6 Rejection of major aspects of being – body, mind, spirit – DFT 2.2 Aggressiveness and danger to self or others, including therapist – DFT 2.3 Excessive fear and anxiety, lack of serenity and calmness – DFT 2.4 No confidence/demoralization/low ego/pessimism – DFT 2.6 Failure to do work due to dishonesty with self and therapist, crisis-orientation, denial and blaming – DFT 2.7 Inflation of self (grandiosity, excessive narcissism) – DFT 2.8

Table 4.4 Diagnosis of the Frequency of Thoughts (DFT): quantitative ranking of immature levels of thought without self-awareness (adapted from Appendix on Measurement of Thought by Cloninger, Feeling Good: The Science of Well-Being, Oxford University Press, 2004)

DFT value

Descriptor of thought content

(Lack of Hope) 2.9 2.8

Basic confidence and responsibility Primary narcissism (Passive-avoidance vs Grandiosity)

(Lack of Self-respect) 2.7 2.6 (Lack of Self-Acceptance) 2.5 2.4 (Lack of Tolerance) 2.3 2.2 (Lack of Trust) 2.1 2.0

Negative fantasy (superstition) vs Positive fantasy (romanticism) Devaluation vs Idealization Basic trust (Helpless surrender vs Lying and exploiting) Criticism and reproach vs Validation Hypochondriasis vs Denial Mistrust (Ignoring information vs Seeking honors) Worry vs Over-compensation Aggression & condemnation vs Seduction & Flattery Hate & Unacceptability vs Eroticism Hopelessness & suicidality vs Ostentation Emptiness (Fear of Annihilation vs Annihilating others)

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Table 4.4 ranks thoughts of increasing coherence from the bottom (2.0, emptiness) to the top of the lowest of the five planes of human thought (2.9, basic confidence and responsibility). Essentially the obstacles to effective treatment are manifestations of the lack of self-awareness in people who have severe personality disorder. The most difficult obstacle is emptiness, which is characteristic of people with the least self-awareness and the least capacity to value life. In other words, severe personality disorders are the essential test of the limits of therapeutic interventions. In principle, each problem listed in Tables 4.3 and 4.4 can be approached with ingenuity, but there is no guarantee of success because the patient must ultimately do the work to develop someone or something that they value in life, thereby becoming motivated to grow in self-awareness. For example, thoughts with little or no self-awareness include feelings of emptiness or hopelessness and homicidal and/or suicidal ideation. In such situations, there is little the therapist can do except to remain hopeful and compassionate while helping to provide safe containment and to stabilize the patient, as described by Bert van Luyn in Chapter 10. Considerable ingenuity is required often to identify something that the patient values enough to want to stay alive and do the work needed to experience the beginnings of happiness. When the patient will do little or no work, medications provide a passive means to stabilization to prepare the patient for subsequent psychotherapeutic work. Ultimately the effectiveness of treatment depends on the patient as well as on the therapist and their relationship. Every patient must find value in their being alive in order to be motivated to work to discover how to live even more happily. They can do this using whatever strengths and intelligence they have, facilitated by experiences that the therapist may help to provide and encourage. A therapist may know well what work the patient must do, but the therapist cannot do the work for the patient to achieve well-being. When the patient is not ready to do the work, we can do what we can to provide a safe, containing environment, medications, encouragement, validation and respect for their dignity as human beings, and problem-solving while the patient progresses in self-awareness at the pace they want or can achieve with their particular abilities and situation. The view I am expressing differs in emphasis, but not fundamentally, from the views expressed by John Clarkin in Chapter 2 regarding differential therapeutics (The treatment of choice: what method fits whom?). I have described a common pathway by which self-awareness develops, which leads to a flexible approach to universal intervention. In other words, I think all humanity shares a common pathway to well-being. However, everyone is also unique in the way they traverse that common pathway because of different biological, psychological, social, and spiritual influences on each person’s pattern of development and their human capacity for freedom of choice and creative invention. As a result, I find it more effective to think in terms of what is the common path and to allow for flexible

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deviations from the modal sequence of development because it emphasizes the unity of perspective that drives the real motivators of well-being – hope, love, and faith. This is only a difference of emphasis from the search for matching different patients to different treatments except that the perspective of separateness has always quickly deteriorated into interpretations that lead to fear, alienation, and stigma. In addition, we must also recognize that some of the obstacles to patients achieving well-being reside in the therapists also, as also noted by John Clarkin in chapter 2. Effective psychotherapy is much more than the effective dispensing of techniques to program and condition subjects or to manage their perceptions like gurus and propagandists. In addition to the common facilitative conditions that a therapist is expected to provide (Hollon, 1984), there is the sensitive issue of the role of spirituality in therapeutic practice (Post et al., 2000). I think a major barrier to effective therapy is the anti-spiritual attitude of many psychiatrists and psychologists, which interferes with their addressing the spiritual needs of their patients, as I described in the introduction. An effective working alliance requires that the therapist seeks to understand the meaning of the patients’ stories in the context of the patients’ beliefs, and family and cultural values. A therapist simply cannot do that if they are insensitive to the spiritual and cultural background of the patient, so many medical schools are conducting training on spirituality to improve physicians’ awareness and sensitivity to spiritual issues (Post et al., 2000). A second obstacle within therapists is the overvaluation of the intellect with relative disregard for the body and spirit. Exposure to nature, physical exercise, balanced diets, and avoidance of drugs and alcohol can be crucial for stabilization in patients with personality disorders. Exposure to inspiring music and art can awaken an appreciation of life. Third, and most generally, as therapists develop their own well-being, they also grow in their capacity to establish and maintain an effective working alliance with challenging patients. We all have work to do in the development of well-being, and fortunately the therapist need only be a little more well than their patient in order to be of assistance in a working alliance.

R EF EREN CES Bateman, A. and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-based Treatment. Oxford: Oxford University Press. Beck, A. T. (1996). Beyond belief: a theory of modes, personality, and psychopathology. In P. M. Salkovskis (ed.) Frontiers of Cognitive Therapy. New York: Guilford Press, pp. 1–25. Beck, A. T. and Freeman, A. (1990). Cognitive Therapy of Personality Disorders. New York: Guilford Press.

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C. Robert Cloninger Bulik, C. M., Sullivan, P. F., Joyce, P. R., Carter, F. A. and McIntosh, V. V. (1998). Predictors of 1-year treatment outcome in bulimea nervosa. Compr Psychiatry 39: 206–214. Burns, D. D. (1980). Feeling Good: The New Mood Therapy. New York: William Morrow & Co. Chalmers, D. J. (1996). The Conscious Mind: In Search of a Fundamental Theory. New York: Oxford University Press. Cloninger, C. R. (2000). A practical way to diagnose personality disorder: A proposal. J Personal Disord 14(2): 99–108. Cloninger, C. R. (2004). Feeling Good: The Science of Well Being. New York: Oxford University Press. Cloninger, C. R. (2005). Antisocial personality disorder: a review. In M. Maj, H. S. Akiskal, J. E. Mezzich and A. Okasha (eds.) Personality Disorders: Evidence and Experience in Psychiatry, Vol. 8. London: John Wiley and Sons, pp. 125–129. Cloninger, C. R. (2007). The Science of Well-Being: The essentials of psychopathology. New York: Oxford University Press, in press. Cloninger, C. R. and Svrakic, D. M. (1997). Integrative psychobiological approach to psychiatric assessment and treatment. Psychiatry 60: 120–141. Cloninger, C. R. and Svrakic, D. M. (2000). Personality disorders. In B. J. Sadock and V. A. Sadock (eds.) Comprehensive Textbook of Psychiatry. New York: Lippincott Williams & Wilkins, pp. 1723–1764. Cloninger, C. R., Svrakic, D. M. and Przybeck, T. R. (1993). A psychobiological model of temperament and character. Arch Gen Psychiatry 50: 975–990. Cloninger, C. R., Svrakic, N. M. and Svrakic, D. M. (1997). Role of personality self-organization in development of mental order and disorder. Dev Psychopathol 9: 881–906. Danner, D., Snowdon, D. A. and Friesen, W. V. (2001). Positive emotions in early life and longevity: findings from the nun study. J Pers Soc Psychol 80: 804–813. D’Souza, R. F. and Rodrigo, A. (2004). Spiritually augmented cognitive behavioral therapy. Austr Psychiatry 12(2): 148–152. Emmons, R. A. and McCullough, M. E. (2003). Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol 84(2): 377–389. Farmer, A., Mahmood, A., Redman, K., Harris, T., Sadler, S. and HcGuffin, P. (2003). A sib-pair study of the temperament and character inventory in major depression. Arch General Psychiatry 60(5): 490–496. Fava, G. A., Rafanelli, C., Cazzaro, M., Conti, S. and Grandi, S. (1998a). Well-being therapy: a novel psychotherapeutic approach for residual symptoms of affective disorders. Psychol Med 28(2): 475–480. Fava, G. A., Rafanelli, C., Grandi, S., Conti, S. and Belluardo, P. (1998b). Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings. Arch Gen Psychiatry 55(9): 816–820. Fava, G. A., Ruini, C., Rafanelli, C., Fuios, L., Salmaso, L., Mangelli, L. and Sirigatti, S. (2005). Well-being therapy of generalized anxiety disorder. Psychother Psychosom 74(1): 26–30. Frankl, V. E. (1959). Man’s Search for Meaning: An Introduction to Logotherapy. New York: Simon & Schuster.

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Enhancing positive dimensions of personality for cure Frankl, V. E. (1978). The Unheard Cry for Meaning: Psychotherapy and Humanism. New York: Pocket Books. Hayes, S. C., Strosahl, K. D. and Wilson, K. G. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press. Hollon, S. D. (1984). Final report: System for rating psychotherapy audiotapes. Bethesda, MD: U.S. Department of Health and Human Services. Horvath, A. O. and Greenberg, L. S. (1989). Development and validation of the working alliance inventory. J Counsel Psychol 36: 223–233. Huppert, F. A. and Whittington, J. E. (2003). Evidence for the independence of positive and negative well-being: implications for quality of life assessment. Br J Health Psychol 8: 107– 122. Kandel, E. R., Schwartz, J. H. and Jessell, T. M. (2000). Principles of Neural Science. New York: McGraw-Hill. Larson, D. B., Thielman, S. B., Greenwold, M. A. et al. (1993). Religious content in the DSM-III-R glossary of technical terms. Am J Psychiatry 150(12): 1884–1885. Lieberman, J. A., Stroup, T. S., McEvoy, J. P. et al. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New Engl J Med 353(12): 1209–1223. Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Luty, S. E., Joyce, P. R., Mulder, R. T., Sullivan, P. F. and McKenzie, J. M. (1999). The relationship of dysfunctional attitudes to personality in depressed patients. J Affect Disord 54: 75– 80. Ma, S. H. and Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol 72(1): 31–40. Murray, C. J. L. and Lopez, A. D. (eds.) (1996). A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. [The Global Burden of Disease and Injury Series.] Cambridge, MA: Harvard University Press. Myers, D. G. and Diener, E. (1996). The pursuit of happiness. Sci Am 273: 70–72. Post, S. G., Puchalski, C. M. and Larson, D. B. (2000). Physician and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 132(7): 578–583. Robins, L. N. (1966). Deviant Children Grown up: A Sociological and Psychiatric Study of Sociopathic Personality. Baltimore, MD: Williams and Wilkins. Seligman, M. (2002). Authentic Happiness: Using the New Positive Psychology to Realize your Potential for Lasting Fulfillment. New York: Free Press. Sheppard, L. C. and Teasdale, J. D. (2000). Dysfunctional thinking in major depressive disorder: a deficit in metacognitive monitoring. J Abnorm Psychol 109(4): 768–776. Svrakic, D. M., Whitehead, C., Przybeck, T. R. and Cloninger, C. R. (1993). Differential diagnosis of personality disorders by the seven factor model of temperament and character. Arch Gen Psychiatry 50: 991–999. Teasdale, J. D., Segal, Z. V., Williams, J. M., Ridgeway, V. A., Soulsby, J. M. and Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 68(4): 615–623.

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C. Robert Cloninger Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S. and Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psychol 70(2): 275–287. Tichener, V. and Hill, C. E. (1989). A comparison of six measures of working alliance. Psychother Res Pract 26: 195–199. Tome, M. B., Cloninger, C. R., Watson, J. and Isaac, M. T. (1997). Serotonergic autoreceptor blockade in the reduction of antidepressant latency: personality and response to paroxetine and pindolol. J Affect Disord 44: 101–109. Vaillant, G. E. and Milofsky, E. (1980). Natural history of male psychological health: IX. Empirical evidence for Erikson’s model of the life cycle. Am J Psychiatry 137: 1348–1359. Walsh, B. T., Seidman, S. N., Sysko, R. and Gould, M. (2002). Placebo responses in studies of major depression: variable, substantial, and growing. J Am Med Assoc 287(14): 1840–1847.

5 5

Personality disorders from the perspective of child and adolescent psychiatry Arnold Allertz and Guus van Voorst

When do personality disorders begin? Is personality fixed in late adolescence or early adulthood? Are personality traits distinguishable after birth or in childhood? There are no definitive answers to these questions as yet and there is obviously much to learn. Nevertheless, long-term studies point to considerable stability in personality even when assessed in adolescence. Moreover, as Paris (2003) noted in his excellent overview of the course of personality disorders from childhood till late adulthood, it does seem possible to identify some precursors of personality disorder in childhood and early adolescence. In this chapter, we highlight some developmental aspects of personality and personality disorders from the perspective of child and adolescent psychiatry. Developmental aspects of personality disorders Developmental psychopathology is the study of the developmental processes that contribute to the formation of, or resistance to, psychopathology (Wenar and Kerig, 2000). Many studies from this field suggest that vulnerability – adversities and psychopathology in infancy and early childhood – may lead to chronic and profound psychopathology in later life. In this section, we discuss five topics that are relevant in the development of psychopathology, especially personality disorders, in infants and young children: heredity, prenatal issues, attachment, temperament, and maltreatment. Heredity

Twin and family studies show that genes influence the susceptibility to acquire a personality disorder. For example, a Norwegian twin study by Torgersen and colleagues showed that personality disorders generally were 60% heritable (Torgersen et al., 2000). Coolidge et al. (2001) in a twin study on 112 children  C Cambridge University Press 2007

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found an even higher heritability in personality disorder features in 4- to 15-yearold children. Adoption studies of antisocial personality disorders have showed substantial heritable influences (Cloninger, 2005). The interaction between genes and environmental factors are thought to lead to the biological basis of traits. This process starts a long time before birth. In a study on 3873 twin pairs at age 3 and 1924 twin pairs at age 7, Valk et al. (2003) found that genetic factors accounted for 66% of the phenotypic stability of so-called internalizing problems and for 55% of the phenotypic stability on externalizing problems. Genes were found to be the most important factor for the continuity in problem behaviors in children. Shared environmental influences accounted for 23% and 37% of the phenotypic stability of internalizing and externalizing problems, respectively. We will discuss the relation between personality disorders and childhood externalizing and internalizing behavior later on in this chapter. Prenatal issues

The interaction between child and environment starts with the interaction between the unborn child and its mother. The mother herself is influenced by biological, psychological, and social factors. Addressing the psychological and sociological issues, Stern (1995) discussed several themes that emerge for a woman who becomes a mother: (1) can she maintain the life and growth of the baby?; (2) can she engage emotionally in an authentic way with the baby, and will that engagement assure the baby’s psychic development?; (3) will she know how to create and permit the necessary support system to fulfill these functions?; (4) will she be able to transform her self-identity to permit and facilitate these functions? Stern calls these four mental themes the “motherhood constellation.” Problems in the motherhood constellation may lead to maternal stress that might lead to abnormal development of the fetal brain. Animal studies support this idea (Huizink et al., 2004). The offspring of animals stressed during pregnancy are overactive and have impaired negative feedback regulation of the hypothalamic–pituitary–adrenergic (HPA) axis. This consistent finding may reflect a physiological mechanism that leads to the development of psychopathology. In a prospective study, Huizink et al. (2002) showed that maternal stress was associated with temperamental problems of the infant at 8 months of age. The mechanism is supposed to be hormonal: increased levels of the mother’s stress hormones lead to increased placental levels of these hormones and hence increased fetal exposure to stress hormones. This leads to a decrease in stresshormone receptors in the hippocampus, which mediates the stress response. This decrease is associated with decreased sensitivity, which may lead to difficulties regulating stress responses. This mechanism enhances the risk of later behavior problems, such as schizophrenia, anxiety, mood disorders, suicidal behavior, and

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antisocial personality disorder (Dingfelder, 2004; Huizink et al., 2004). Although maternal prenatal stress is associated with a wide range of psychopathology in the child, the effect on the child’s temperament suggests at least some connection with personality development. Temperament is defined as the inborn tendencies that shape behavior and emotion. Features of temperament may lead to personality traits, which are defined as stable characteristics affecting behavior, emotion, and cognition in individuals by social learning (Paris, 2003). Attachment

After birth, the infant, having lost its physical attachment to the mother’s body and the protection and nurturance it provides, must turn to other sources of attachment to survive and obtain the nourishment and stimulation needed for further development (Millon and Davis, 1995). Attachment behaviors may be viewed as an attempt to reestablish the unity lost at birth. Attachment is the observable result of the ongoing process that develops between the infant and its primary caregiver in the first 2 years of life. Siegel (1999) suggests the following about the importance of attachment in infancy on the developing mind: Environmental factors play a crucial role in the establishment of synaptic connection after birth. For the infant and young child, attachment relationships are the major environmental factors that shape the development of the brain during its period of maximal growth. Therefore, caregivers are the architects of the way in which experience influences the unfolding of genetically preprogrammed but experience-dependent brain development. Genetic potential is expressed within the setting of social experiences, which directly influence how neurons connect to one another. Human connections create neuronal connections.

The Adult Attachment Interview (AAI) (Main and Goldwyn, 1994) and the Strange Situation Procedure for the child are instruments for the assessment of attachment over time. The interaction between babies who are a few months old and their primary caregiver can be measured by videotaped observation in three successive phases. In the first phase, lasting 2 min, the infant is secured in an infant seat and the mother is asked to engage in her “normal” face-to-face play with her baby (without toy or doll). Then she is asked to maintain eye contact with the baby but with a still face and without any reaction to the child’s behavior. In the third 2-min phase, the mother again plays with her baby. Crandel et al. (2003) used this procedure to compare 8 mothers with borderline personality disorder with 12 mothers without a psychiatric disorder. Mothers with borderline personality disorder had a particular pattern of mother–infant interaction: they were more intensive and intrusive toward their infants and during the still face period their infants showed more disorganized behavior with increased looking away and dazed looks. Crandell suggests that these behaviors represent

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early signs of potentially dysfunctional infant self-regulation. According to Barkley (1997), self-regulation and self-control are interchangeable concepts. Problems in self-control are related to externalizing disorders that may lead to psychopathology, such as attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD), the latter of which can be considered as a direct precursor of an Axis II disorder (Paris, 2003). The relationship between attachment patterns and personality disorder was also explored in adolescents by Nakash-Eisikovits et al. (2002). In a study on 294 patients aged 14–18 years, they found that disorganized/unresolved attachment was strongly associated with multiple forms of personality pathology. However, research on attachment representations with the AAI shows that the current attachment representations are highly influenced by more recent relationships. There does not appear to be a direct link between the parent’s early attachment experiences and their parenting behavior. Secure attachment experiences later in life are supposed to provide a secure base for exploring and working through adverse childhood experiences (Van IJzendoorn and Bakermans–Kranenburg, 1997). Fonagy et al. (1991) applied the AAI to pregnant women. He found that reported attachment styles were predictive for attachment patterns in the newborn 9–16 months later. Thus both maternal stress and maternal attachment experiences affect the temperament and attachment status of the infant. The regulation of affect in the intense relation between infant and primary caregiver is thought to be crucial for the developing brain. Young children can manage negative emotions better within a secure relationship because of soothing and effective responses by the caregiver. By providing this external form of affect regulation, caregivers help their infants gradually develop the ability to regulate their own affect. In inconsistent and rejecting caregiving, infants and toddlers may underregulate their own affect or restrict it excessively. As the primary neurophysiological pathways are developed in infancy and toddlerhood, the basics of human coping with the environment are founded in this period. In infant research, both intensive and methodical observation of mother–infant interactions in a standard situation and standardized interviews in which mothers recall their own childhood social experiences demonstrate a relation between the infant’s ability to cope with stress, the infant’s development, and maternal psychopathology (Crandell et al., 2003; Fonagy et al., 1991; Van IJzendoorn, 1995). Temperament

Many authors define problems in temperament as a precursor in the development of personality disorders. For example, Paris (2003), discussing the implications of childhood temperament for the development of personality disorders, suggested that children who develop personality disorders probably begin life with

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an abnormal temperament. Rothbart and Putman (2002) defined temperament as “constitutional based individual differences in reactivity and self-regulation, influenced over time by heredity and experience.” Temperament refers to behavior that usually appears in the first year of life and it is supposed to have biological and genetic origins. Temperament is a basic feature of personality and therefore of personality disorders. Although adverse events during childhood increase the overall risk for psychopathology, their effects are stronger on individuals who have a temperamental disposition. Rothbart and Putman (2002) found three dimensions in infant temperament that are considered to be related to personality factors in adults. The first dimension is called surgency and reflects a broad dimension from shyness to high-intensity pleasure. The second dimension, distress to limitations, fear and sadness, corresponds to negative emotionality and neuroticism. The third dimension, affiliation, orienting, was defined by duration of orienting, low-intensity pleasure, soothability, and cuddliness. Oldehinkel et al. (2004), in a study on 2230 preadolescents, suggested that surgency marks the direction between the conditional probability of internalizing (shyness) or externalizing problems (high-intensity pleasure). In this study, distress to limitations was mainly related to maladaptation in general and can be seen as a severity marker. Children with high levels of aggression and irritability are often in chronic conflict with parents, peers, and teachers and tend to respond to these conflicts with more aggression. Children with behavioral inhibition elicit overprotective responses, which only exacerbates the problem. When these feedback loops spiral out of control, they can exaggerate existing traits and become difficult to change later in life. Maltreatment

Child maltreatment, including physical abuse, sexual abuse, neglect, and psychological abuse, has a profound impact on the developing individual. The work of Dante Cicchetti and his group has demonstrated the devastating consequences of child maltreatment on children, families, and society (Cicchetti and Lynch, 1995). Maltreated infants have numerous difficulties in their emotional self-regulation. They may show excessive amounts of negative affect or blunted affect expression. Affect regulatory problems have been shown to impair the social competence of school-age maltreated children’s interaction with their peers. High rates of childhood abuse and neglect are reported in adults with personality dysfunction (Goodman et al., 2004). Epidemiologic studies indicate that children exposed to early adverse events are at increased risk for the development of depression, anxiety disorder or both (Heim and Nemeroff, 2001). Many individuals with a personality disorder, especially borderline personality disorder (BPD), have a history of childhood maltreatment or abuse. In a study of 358 patients with BPD,

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Zanarini and colleagues (1997) found that 91% of the patients reported abuse and 92% of the patients reported neglect. Goodman et al. (2004) estimate that the overall rate of childhood sexual abuse in BPD ranges from 40% to 70%, compared to an overall rate of 19%–24% for other Axis-II patients. Most of the studies were conducted on samples of hospitalized patients. A meta-analysis of 21 reports comprising 2414 subjects, by Fossati et al. (1999), showed only an overall moderate association between later reported childhood sexual abuse and BPD diagnosis. The role of trauma in the development of personality disorder and especially BPD remains unclear. Personality disorders seem to be unrelated to specific abuses, but they may relate to more enduring aspects of interpersonal and family environments in childhood (Goodman et al., 2004). One of the ways in which adversity, especially trauma, may influence the development of personality disorder is via its effects on stress responsivity. Neuroendocrine studies have shown that stress in early life may lead to increased corticotrophin-releasing factor (CRF) activity and sensitization of the HPA axis. Recent findings on HPA functioning in personality disorders give biological support to the notion that BPD is not a trauma spectrum disorder and that the underlying biology of BPD is distinct from that of post-traumatic stress disorder (Goodman et al., 2004; Rinne, 2002). Post-traumatic stress disorder (PTSD) can be considered as a frequent comorbidity in personality disorders. For example Golier et al. (2003) found that PTSD existed in 17.8% of their cohort of personality-disordered individuals and that it existed in 25% of the subjects with BPD. Diagnosis of personality disorders in children and adolescents DSM-IV-TR defines personality disorder as inflexible traits or patterns of perceiving, relating to and thinking about the environment and oneself, which are exhibited in a wide range of social and personal contexts. The stable patterns can be traced back to adolescence or early childhood and are leading to chronic difficulties that can endure for a lifetime (APA, 2000). Paris (2003) concludes this means that personality disorders are chronic diseases by definition. Personality disorder categories may be applied to children and adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or episode of a DSM-IV Axis-I disorder. According to Kernberg et al. (2000), children exhibit distinctive traits and patterns of perceiving, relating and thinking about the environment and themselves, including traits such as impulsivity, introversion, egocentricity, novelty-seeking, inhibition, sociability, activity, and many others. Kernberg added that these traits and patterns endure across time and situation, and warrant the designation of personality

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disorder regardless of the children’s age, when they: (1) become inflexible, maladaptive, and chronic; (2) cause significant functional impairment; and (3) produce severe subjective distress when the features are present for at least one year. In child and adolescent psychiatry, clinicians are usually cautious about diagnosing personality disorders in children and adolescents. Paris (2003) contends that this is because psychiatrists have always preferred to believe that psychopathology in children and adolescents is more malleable than in adults. His experience is that patients tend to earn a personality disorder diagnosis only at the point when their treatment has failed. In our opinion, clinicians working with children tend to be optimistic about the developmental possibilities. Diagnosing a personality disorder in childhood can be seen as giving young people a life-long stigma. However, Block et al. (1991), Garnet et al. (1994) and others have shown that personality disorders in adolescence do exist. They described groups of adolescents with personality disorders who continue to have serious problems in adulthood although the specific personality disorder diagnosis may change. Pinto et al. (1996) also reported borderline personality disorders in youngsters. According to the DSMIV-TR manual (DSM-IV-TR; APA, 2000), specific maladaptive traits that do not meet the threshold for a personality disorder may also be listed on Axis II. In our own clinical practice, we use this possibility to describe maladaptive personality in children on DSM-IV Axis II. For example in those cases we record: “Axis II: V71.09 No diagnosis. Schizotypal personality traits.” Childhood psychopathology and its relation with personality disorders One of the main problems in relating childhood psychopathology to personality disorders is the different language used by child and adult psychiatrists. Child psychiatry is reluctant to classify problems of children on Axis II and, as mentioned earlier, childhood psychopathology is usually diagnosed on Axis I. Hence from a classification perspective, there are few direct links between childhood psychopathology and adult Axis II psychopathology. In ordering children’s problems, three profiles are often used: externalizing, internalizing, and thought disorders (Achenbach, 1991). Frequently used externalizing diagnoses are ADHD and CD. Oppositional defiant disorder (ODD) is often diagnosed when there is a mixture of externalizing and internalizing symptoms. These disorders are also called disruptive behavioral disorders. Anxiety disorders, mood disorders and obsessive compulsive disorders (OCD) are frequently diagnosed in the internalizing category. In the spectrum of Thought disorders we find DSM-IV-TR autistic spectrum disorders. Externalizing disorders in childhood often predict Axis-II-type problems in adulthood (Bernstein et al., 1996; Kasen et al., 1999). Prospective cohort studies

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show a positive association between rule-breaking or externalizing behavior in young children and adult disruptive disorders (Hofstra et al., 2002). Self-control problems are reported from age 2 years and are more common in boys than in girls. In children, the disruptive behavior disorders such as CD, ODD, and ADHD are highly co-morbid with each other (50%–70%). Hyperactive and under controlled behavior are the precursors of ADHD, especially the predominantly hyperactiveimpulsive type and the combined type. Hofstra et al. (2002) found in a large Rotterdam cohort study that attention deficit or inattentively alone does not predict any form of adult psychopathology. Hyperactivity symptoms in ADHD are reported in young children while attention problems are reported from age 6 and up (Barkley, 1997). Regarding the adult outcome of clinical ADHD, with high percentages of substance abuse and antisocial personality problems, it seems that only problems in self-control in children with ADHD are predictive for adult personality problems. Internalizing disorders in childhood such as early-onset dysthymia, chronic depression, and anxiety disorders often constitute a precursor of Axis-II disorders in cluster C (Bernstein et al., 1996; Kasen et al., 1999; Mavissakalian et al., 1993; Pepper et al., 1995). Thought disorders, e.g., deficits in cognitive and social cognitive processes, may lead to several developmental problems and are associated with Axis-II disorders in adulthood (Olin et al., 1997). In a follow-up study of 32 children diagnosed as schizoid (DSM-III), Wolff et al. (1991) found that 24 of them met the criteria for DSM-III schizotypal personality disorder in adulthood (two were diagnosed with schizophrenia). The children diagnosed as schizoid were characterized as solitary and finding group activities stressful, with obstinacy and aggressive outbursts at school. They were preoccupied with their own interests and ideas and had a lack of empathy. Van der Gaag (1993) stated that these problems could be considered to have a constitutional basis. In his opinion, children with severe problems in the domain of social, communicative, emotional, and cognitive functioning present as a pervasive developmental disorder but fail to satisfy the complete set of diagnostic criteria for autistic disorder. He found that these children received various diagnoses such as pervasive developmental disorder not otherwise specified, atypical developmental disorder, schizoid personality disorder in childhood, borderline disorder in childhood, and autism spectrum disorder. In his follow-up study, Van der Gaag (1993) used the diagnosis multiplex developmental disorder (Cohen et al., 1986) to define children with this type of psychopathology. More recently, this condition has been called multiple complex developmental disorder (MCDD). Van der Gaag’s conclusion is that the disorder appears to be highly persistent and that it seems to prelude socially impaired personality disorders that become apparent in mid adolescence. In a follow-up study of 12 MCDD children, Van der Gaag (1993) found that two

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individuals were diagnosed with schizophrenia and seven with personality disorder (two schizotypal, four schizoid, and one borderline). Paris (2003) carried out a systematic study of borderline pathology in children attending daytime treatment. His findings at age 15 indicated that these children continued to function at a lower level than children with other diagnoses. Most studies of children with this kind of psychopathology found that the psychosocial risk factors are strikingly similar to those described by adults with borderline personality disorder, namely dysfunctional families, trauma, neglect, and separation (Bemporad et al., 1982; Paris, 2003). Both borderline psychopathology of childhood and MCDD are associated with neuropsychological abnormalities (Paris, 2003) and constitutional defects (Van der Gaag, 1993). Children diagnosed with MCDD and those with BPD probably represent the same group of severely handicapped children. They are often, but not always, confronted with severe psychosocial adversities. These children tend to develop different forms of personality problems in adulthood and a minority also develop severe Axis-I disorders such as schizophrenia. Prevention and treatment Prevention

Prevention requires a targeted approach (Paris, 2003) in which the population of children who are most likely to develop disorders is reached. Since childhood precursors of most personality disorders are still difficult to identify, it is hard to plan a rational strategy for preventive interventions. A simple approach would be to identify families at risk for maltreatment, abuse, and neglect using prenatal screening of mothers and fathers. Those considered to be high risk could be engaged in a program of home-visiting, behavioral parent training, and community-based multimodal programs. These programs have been shown to be successful in reducing the risk for physical child abuse (Carr, 2003). Particular attention should be given to developing early intervention programs for pregnant women considered to be vulnerable due to an attachment style that puts them at risk. Treatment

Childhood symptoms may set in motion a pattern of maladaptive social behaviors, which elicit negative reactions from the environment which in time become an integral part of the personality system. Early interventions may be helpful to circumvent these risks. Olds et al. (1998) showed that regular nurse home-visits to high-risk mothers, from the time of birth to the child’s second birthday, had a significant effect in reducing antisocial behavior and substance abuse in children when they reached adolescence. Kernberg et al. (2000) points out that children

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with moderate or severe psychopathology rarely outgrow such symptoms. Boys with externalizing behavior tend to show adult externalizing behavior (homotypic continuity) and girls with disruptive disorders tend to show both externalizing and internalizing psychopathology in adulthood (heterotypic continuity). Cognitive behavioral interventions with children with conduct disorders have been shown to be effective (Kazdin, 2000), although many patients drop out of therapy and improvements are not always maintained in the long term. Pharmacologic interventions can also be useful in the treatment of disruptive disorders in childhood and adolescence. Both psychostimulants, such as methylphenidate, and atomoxetine have been shown to be effective in decreasing ADHD symptoms. Although effective psychopharmacologic treatments of conduct disorders have not been identified, conventional neuroleptic agents are the most commonly described drugs. Atypical antipsychotics such as risperidone appear to be effective in controlling severe disruptive behaviors in children with below-average IQ (Findling et al., 2004). Given the importance of the family in the etiology of psychopathology, it is always necessary to work with the family when a child is in trouble. “Child treatment is de facto family context therapy” states Kazdin. He identified parent management training (PMT) as a well researched technique in psychotherapy for children and adolescents with disruptive behavioral disorders (Kazdin, 2000). Also functional family therapy (FFT), multisystemic therapy (MST) and multidimensional family therapy (MDFT) have demonstrated consistently positive outcomes in the treatment of CD, ADHD, and ODD. In addition to etiological arguments, we also need to bear in mind that children with disruptive disorders place a considerable burden on parents, especially mothers. In a study on the relation between childhood pathology and family burden, the parents of children with externalizing behavior experienced their children as a higher burden in parenting than parents of children without psychiatric disorders or children with internalizing behavior alone (Van Voorst et al., 2004). These families may benefit from a supportive intervention program, especially when their parenting skills are poor. Moreover, parents of children with disruptive psychiatric disorders often experience social problems in their neighborhood. A hostile environment leading to social stigmatization, isolation, and legal problems are all possible consequences of a childhood disruptive disorder. As a result of this, child psychiatric services are often confronted with resistance in parents who are in denial, tend to avoid contact with mental health professionals or are hostile toward them. Hence working with these families who are often stuck in abusive patterns can be very discouraging. Therefore special attention has to be paid to mental health care workers and their teams facing these parents and their children in every day practice.

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Summary There is evidence that disruptive behavior in early childhood predicts disruptive adulthood behavior in boys. Beside this homotypic continuity, the overall heterotypic continuity of psychopathology from childhood into adulthood supports the cautiousness of child and adolescent psychiatrists and psychotherapists in diagnosing personality disorders in children and adolescents. Genetic and environmental factors may both predispose to the development of personality and personality disorders. Environmental factors influence childhood development even before birth. Preventive attention has to be paid to adult patients in their role as parent. Family-based interventions, as well as child, individual and group treatment are important for the prevention and treatment of children at risk for personality disorders.

R EF EREN CES Achenbach, T. M. (1991). Integrative Guide to the 1991 CBCL/ 4-18, YSR, and TRF Profiles. Burlington, VT: University of Vermont, Department of Psychiatry. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn., text revision. Washington, DC, American Psychiatric Association. Barkley, R. A. (1997). ADHD and the Nature of Selfcontrol. New York: The Guilford Press. Bemporad, J. R., Smith, H. F., Hanson, G. and Chicchetti, D. (1982). Borderline symptoms in childhood: criteria for the diagnosis. Am J Psychiatry 139: 596–602. Bernstein, D., Cohen, P., Skodol, A., Bezirganian, S. and Brok, J. S. (1996). Childhood antecedents of adolescent personality disorders. Am J Psychiatry 153(7): 907–913. Block, J. H., Gjerde, P. F. and Block, J. H. (1991). Personality antecedents of depressive tendencies in 18-years-olds: a prospective study. J Pers Soc Psychol 60(5): 726–738. Carr, A. (ed.) (2003). Prevention: What Works with Children and Adolescents: a Critical Review of Psychological Prevention Programmes for Children, Adolescents and their Families. Brighton: Taylor and Francis. Cicchetti, D. and Lynch, M. (1995). Failures in the expectable environment and their impact on individual development: the case of child maltreatment. In D. Cicchetti and D. J. Cohen (eds.) Developmental Psychopathology, Vol. 2. New York: John Wiley, pp. 32–71. Cloninger, C. R. (2005). Genetics. In J. M. Oldham, A. E. Skodol and D. S. Bender (eds.) Textbook of Personality Disorders. Washington, DC: American Psychiatric Press. Cohen, D. J., Volkmar, F. R. and Paul, R. (1986). Issues in the classification of pervasive developmental disorder: history and current status of nosology. J Am Acad Child Adolescent Psychiatry 25: 158–161. Coolidge, F. L., Thede, L. L. and Jang, K. L. (2001). Heritability of personality disorders in childhood: a preliminary investigation. J Pers Disord 15: 33–40.

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Arnold Allertz and Guus van Voorst Crandell, L. E., Patrick, M. H. and Hobson, R. P. (2003). “Still-face” interactions between mothers with personality disorder and their 2-month-old infants. Br J Psychiatry 183: 239–247. Dingfelder, S. F. (2004). Programmed for psychopathology? Stress during pregnancy may increase children’s risk for mental illness, researchers say. Monitor Psychology (35)2. Findling, R. L., Aman, M. G., Eerdekens, M., Derivan, A. and Lyons, B. (2004). Long-term openlabel study of risperidone in children with severe disruptive behaviors and below-average IQ. Am J Psychiatry 161: 677–684. Fonagy, P., Steele, H. and Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother-attachment at one year of age. Child Dev 62: 891–905. Fossati, A., Madeddu, F. and Maffei, C. (1999). Borderline personality disorder and childhood sexual abuse: a meta-analytic study. J Pers Disord 13: 268–280. Gaag, van der, R. J. (1993). Multiplex Developmental Disorder. An Exploration of Borderlines on the Autistic Spectrum. Urecht: Rijksuniversiteit. Garnet, K. E., Levy, K. N., Mattanah, J. J., Edell, W. S. and McGlashan, T. H. (1994). Borderline personality disorder in adolescents: ubiquitous or specific? Am J Psychiatry 151: 1380–1382. Golier, J. A., Yehuda, R., Bierer L. M. et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. Am J Psychiatry 160: 2018– 2024. Goodman, M., New, A. and Siever, L. (2004). Trauma, genes, and the neurobiology of personality disorders. Ann N Y Acad Sci 1032: 104–116. Heim, C. and Nemeroff, C. B. (2001). The role of childhood trauma in the neurobiology of mood and anxiety disorders: preclinical and clinical studies. Biol Psychiatry 49: 1023–1029. Hofstra, M. B., van der Ende, J. and Verhulst, F. C. (2002). Child and adolescent problems predict DSM-IV disorders in adulthood: a 14-year follow-up of a Dutch epidemiological sample. J Am Acad Child Adolesc Psychiatry 41(2): 182–189. Huizink, A. C., Robles de Medina, P. G., Mulder, E. J. H., Visser, G. H. A. and Buitelaar, J. K. (2002). Psychological measures of prenatal stress as predictors of infant temperament. J Am Acad Child Adolesc Psychiatry 41: 1078–1085. Huizink, A. C., Mulder, E. J. H. and Buitelaar, J. K. (2004). Prenatal stress and risk for psychopathology: specific effects or induction of general susceptibility? Psychol Bull 130: 115– 142. IJzendoorn, van, M. H. (1995). Adult attachment representations, parental responsiveness, and infant attachment: a meta-analysis on the predictive validity of the Adult Attachment Interview. Psychol Bull 117: 387–403. IJzendoorn, van M. H. and Bakermans-Kranenburg, M. J. (1997). Intergenerational transmission of attachment: a move to the contextual level. In L. Atkinson and K. J. Zucker (eds.) Attachment and Psychopathology. New York: The Guilford Press, pp. 135–170. Kasen, S., Cohen, P., Skodol, A. E., Johnson, J. G. and Brook, J. S. (1999). Influence of child and adolescent psychiatric disorders on young adult personality disorder. Am J Psychiatry 156: 1529–1535. Kazdin, A. E. (2000). Psychotherapy for Children and Adolescents. Directions for Research and Practice. New York: Oxford University Press.

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Disruptions in the course of psychotherapy and psychoanalysis Salman Akhtar

Things never do go smoothly in suicides, weddings, and courtships (Mark Twain)

In an aphoristic statement, the quintessentially American psychoanalyst Harry Stack Sullivan is known to have said: “Beware of smoothly going therapy.” At one level, we all attest to the wisdom of this statement. At another level, however, we continue to hold on to the idea that psychotherapeutic endeavors could or should go on without a hitch. Clinical experience shows us otherwise. Our patients “disappoint” us. They walk out, act out, and drop out, leaving us baffled, embarrassed or even resentful. Keeping this in mind, it seems imperative that we attempt to understand what such “disruptions” mean, how they arise, what their dynamics are, and how they can be mended. Other questions also need to be faced; for instance: Are all disruptions “bad?” Do disruptions happen in the course of all psychotherapies or only in the treatments of patients with severe character pathology? Are disruptions avoidable? Are there developmental prototypes for disruptions? In other words, are there normative aspects to the disruptions of dialog between a patient and his or her therapist? And, finally, can disruptions ever be an indication that the treatment is progressing well? The search for preliminary answers to these questions forms the impetus of this chapter. In it, I will (1) offer a definition of the concept of “disruption,” (2) bring together the models of its etiology that seem scattered throughout psychoanalytic literature, (3) describe various manifestations of disruptions with the help of brief clinical vignettes, (4) discuss the technical dilemmas in dealing with these difficult clinical situations, and (5) seek to anchor my recommendations in some childdevelopment observations.  C Cambridge University Press 2007

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Definition The term disruption has no “official” definition. It does not appear in psychiatric (Hinsie and Campell, 1970) and psychoanalytic (Eidelberg, 1968; Laplanche and Pontalis, 1973; Moore and Fine, 1968, 1990; Rycroft, 1972) glossaries. More significantly, the term “disruption” is not listed in the indices of the four most wellrespected books on borderline conditions (Grinker and Werble, 1977; Gunderson, 1985; Kernberg, 1975; Stone, 1990). And yet, as a common-sense phrase, the expression “disruption” is a daily guest in the chamber of clinical discourse. It is used loosely for interruptions of treatment due to reality reasons (e.g., money, relocation, finishing college) as well as for miscarriages of dialog due to psychological reasons within the therapeutic dyad. To bring some order to this laxity of use, I suggest that we restrict the use of the term for the latter situations. Defined in this way, a “disruption” will have occurred when there is: (1) a rupture of communication within the therapeutic dyad, (2) sudden divergence in the agendas of the two parties, and (3) a threat to the safety or continuity of their ongoing work. This operational definition can, in some ways, be taken to reflect what are regarded to be the ingredients of a “working” (Greenson, 1965), “therapeutic” (Brenner, 1979), or “helping” (Thomae and Kachele, 1994) alliance. With vantage points that differ only slightly, these three concepts refer to mutuality of purpose, agreement over methodology, and pact of collaboration throughout the course of treatment, between the patient and the psychotherapist. Disruption is a serious impairment of such an alliance between the two parties. Once we have arrived at this definition, we might begin looking for the underlying motivational factors that cause disruptions of the clinical dialog.

Dynamics Within psychoanalytic literature, there seem to be many etiological models for the occurrence of a disruption. In the following passages, I offer a list of these models. However, in doing so I am not asserting one explanation’s superiority over an other, nor am I suggesting that some, owing to their being “old,” are less valid than others. Neither am I suggesting that these models exist in an exclusive manner: more than one explanation usually applies to patients we see in clinical practice. Moreover, disruption is an interactional event and does not arise only from variables within the patient: the therapist might also contribute to the derailment of the clinical dialog. It is with such caveats that the following models should be approached. Keeping them in mind would help the psychotherapist discern what might be going on at a deeper level with his or her patient.

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Unconscious guilt

Observing that certain patients got worse rather than better upon being understood in a correct fashion, Freud (1923) came up with the idea that an unconscious feeling of guilt was responsible for this unexpected disturbance. “Negative therapeutic reactions” of this sort led the patient to become uncooperative, argumentative, and symptomatic in ways that had been given up. They even impelled the patient to break off treatment. Freud speculated that a profound sense of unworthiness and a need for punishment existed under such disruptions of treatment. While he traced the source of such guilt to subterranean oedipal longings, the fact is that it could emanate from other sources as well. For instance, individuals who have grown up around sickly siblings often carry unmet dependency needs and marked hostility arising out of such deprivation (Akhtar and Kramer, 1999). Inwardly remorseful about this hostility, they might find it difficult to enjoy the benefits of psychotherapy and disrupt its progress. The same applies to those who have lost their parents in their childhood. Such individuals suffer from “survivor’s guilt” (Niederland, 1981), which can propel them to disrupt their treatments. Yet another group of individuals prone to guilt-driven disruptions are those in whom guilt was induced by parents during childhood. If, for instance, a mother makes it a point to repeatedly tell her offspring that her pregnancy and labor with him or her was very difficult and that she almost lost her life in the process, then the child grows up feeling chronically guilty (Asch, 1976). Upon entering psychotherapy as an adult, he or she can hardly bear feeling understood and empathized with by the therapist. A tendency to disrupt treatment often accompanies such inner remorse. Anxious retreat from “higher” level conflicts

A second dynamic of disruptions involves the patient’s regression due to the dread of facing newer intrapsychic conflicts once the intense, splitting-related issues are resolved. Borderline patients, for instance, struggle with an incapacity to tolerate ambivalence. They idealize people and, when those people frustrate them, devalue them. It is no different in the clinical situation: they fluctuate between the extremes of adoring and hating the therapist. At both poles of their experience, matters appear simple and self-evident to them. Both transference configurations, however, lead to a cardboard-like image of the therapist in the patient’s mind. The patient seems incapable of containing the two representations simultaneously, combining them, developing a “total” image, and refining it with tidbits of actual knowledge. With holding and containing functions of the therapist and with the use of “bridging interventions” (Akhtar, 1995, 1998; Kernberg, 1975), these capacities gradually increase. The patient begins to show a capacity for tolerating ambivalence

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and for genuinely knowing others. At this point, new anxieties crop up. It is like going from the frying pan to the fire. Usually pertaining to oedipal fantasies (with all their pressure of intrigue and pain of exclusion), these anxieties cause a regression. Unable to bear exclusion from the real or imagined coupled life of the therapist, the patient once again becomes split, chaotic, and angst-ridden. The treatment ambience which had just become peaceful becomes subject to chaos and acting out. Sadomasochistic need to destroy a helpful situation

Patients with severe personality disorders often have suffered intense frustrations in childhood. Lack of love, chronic neglect, betrayal, physical and sexual abuse, and abandonment via desertion, divorce, or death often figure prominently in their developmental history (Akhtar, 1992, 1995). Such traumas fill them with pain, hurt, and hatred. As a result, when they enter treatment, they desperately want to be supported, praised, and loved. However, they also want to vent their pent-up anger and seek revenge from those who have hurt them (and the re-creations of such people in the transference). This inner pressure to attack caretakers becomes a powerful source of disruptions in their treatment (Kernberg, 1975). A related dynamic emanates from the patient’s envy of the therapist’s capacity to remain calm and composed. The latter’s ability to soothe and make helpful interventions stirs up the patient’s envy (“How can you make me feel better when I myself cannot? What do you have that I lack?”). And, this envy can propel attacks on the therapist and the therapeutic process (Klein, 1946). The life-enhancing function of seeing connections – between past and present, between love and hate, between childhood experiences and transference re-creations, and between the two parental figures – is also attacked. The result of such sadism, envy, “attacks on linking” (Bion, 1959), and assaults on the healthy aspects of one’s own mental functioning (since it is allied with the envy-producing therapist) is serious disruption of clinical work. Retreat due to separation anxiety

Certain disruptions of treatment are caused by anxiety over having a separate existence of one’s own. Narcissistically needy mothers who cannot let go of their children render them vulnerable to unconsciously equating separation with causing injury to them. Upon entering psychotherapy as adults, such “children” experience any increase in distance (from their primary internal objects as well as from the transferential re-creations of them) as anxiety provoking. This, in turn, can cause them to regress and give up the gains derived from therapy. Modell (1965), Asch (1976), and Gruenert (1979) have described such negative therapeutic reactions

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based upon the anxiety of separation. I too have briefly commented elsewhere (Akhtar, 1991) on a patient who, with each progressive movement in her analysis, would develop a fear of abandonment by me and, motivated by this fear, regressively lose her laboriously acquired insights. In a related vein, Miller (1965) suggests that the exacerbation of symptoms during the terminal phase of analysis might also reflect a defense against separation anxiety. Shift in psychic organization

It is conventional psychoanalytic wisdom that better functioning patients are mostly organized around internal conflicts (e.g., “What to do and what not to do? What is the right course if I want to do what I should not do?”) and those with severe personality disorders around internal deficits (e.g., “How to be? How to do this or that?”). However, in day-to-day practice, matters are more complex. All patients turn out to have areas of conflict and areas of deficit in their mental make-up. This is important to know since at the level of conflict, the patient is amenable to seeing hidden meanings in his or her communications. The patient also appears capable of waiting, listening, and cooperating with the therapist. However, when the patient hits an area of deficit, ego regression sets in (Balint, 1968; Killingmo, 1989). Words lose connotations. Language becomes simple. There develops a quality of monotonous repetition to the patient’s demands. Leaving the terrain of “contradiction” and “paradox,” the subjective experience enters the realm of “simplicity” (Akhtar, 1998). If the therapist does not discern this change and shift his of her technique accordingly (see below), then he or she “loses” contact with the patient. Their dialog suffers and a disruption results. Empathic failures of the therapist

While the foregoing dynamics hint at the potential contribution of a therapist to clinical disruptions, more overt situations of iatrogenic impasses also exist. Some of these arise from the therapist’s inexperience and the consequent technical rigidity. Others result from the therapist’s failure of empathy (Kohut, 1977) or from specific countertransference lapses which makes him or her lose touch with the patient’s psychic reality. Under these circumstances, The patient feels misunderstood and unable to get through to the therapist. Perhaps the therapist seems more interested in himself and in his theories than the patient’s concerns. Or, the therapist may seem to be more involved with the patient’s family or other presumed adversaries than with the patient. Sometime the patient has the impression that the analyst is more interested in the patient’s behavior than how he or she feels inside or that the analyst cares more about the analysand than who he or she is. (Wolf, 1995, p. 93)

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As would be readily apparent, this sort of disruption has overlaps with the dynamics associated with the shifting structural organization described above. The only difference is that here the therapist’s contribution is largely emanating from within his or her psyche and is not a response to the altered situation within the patient’s mind.

Manifestations The breakdown of communicative mutuality between the patient and therapist can be of varying degrees. Variables of duration, emotional intensity, threat to the framework of treatment, and risk of violence have to be taken into consideration here. The following clinical vignettes illustrate what can happen in such circumstances and how disruptions range from momentary ruptures of working alliance to broken therapeutic boundaries and threats of physical harm. Case 1 A highly intelligent lawyer with narcissistic personality disorder was in analysis with me. For the first year or so, all she talked about was how she felt unloved by her husband and, during her childhood, by her mother. She never made a comment about me and in effect treated me with an indifference that was quite like she had received from her mother. Then, in the eighteenth month of her analysis, I announced that I had to take a few days off on a rather short notice. The patient responded to the news with immediate acceptance and usual lack of associations. The next day, however, she began her session by telling me that one of her clients had cancelled an appointment that morning. During that hour, she went through her desk drawers and found her home insurance policy. The patient went on to tell me that she got quite upset upon reading parts of that policy. There were too many loopholes, too little coverage! Discerning unmistakable allusions to my impending absence (e.g. “cancelled appointment,” “too little coverage”) in her associations, I said: “Perhaps you find it easier to talk about an insurance policy with loopholes than an analysis with interruptions.” After a long pause, the patient responded in a pained voice: “I can see how you arrived at what you said but it hurt my feelings because I was really worried about the policy and it seems that you are not paying attention to my concern about it.”

Here the “disruption” that occurred was manifested by the long pause during which the patient obviously found it difficult to communicate with me. In quickly unmasking what lay behind a derivative of her feelings about our separation, I had overlooked the patient’s need for such disguise. I had disregarded her need to control the boundaries between her conscious and unconscious psychic life and to yield such control at her own pace. I had gone “too deep” and my intervention had resulted in a “micro-disruption.” Her communicating her distress to me showed

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that she had already bounced back from the momentary rupture of our dialog. A more dramatic example of this is constituted by the following vignette. Case 2 In the throes of a regressive transference, a patient entered my office enraged and waving a finger. Approaching the couch, she said, “I have a lot on my mind today and I want to do all the talking. I don’t want you to speak even a single word!” A little taken aback, I mumbled “Okay.” The patient shouted, “I said, ‘not a word’ and you have already fucked up this session!” Now sitting on my chair behind her, I was more rattled. “Did I do wrong by speaking at all?” I asked myself. As the patient lay on the couch, angry and stiff, I started to think. Perhaps she is so inconsolable today, so intent upon forcing me into the role of a depriving person, that she found a way to see even the gratification of her desire as its frustration. I was, however, not entirely satisfied with this explanation and therefore decided to wait, and think further. It then occurred to me that maybe she was rightly angered by my saying “Okay.” In my agreeing to let her have omnipotent control over me, I had asserted my will and thus paradoxically deprived her of the omnipotence she seemed to need. I was about to make an interpretation along these lines, when it occurred to me that by sharing this understanding, I would be repeating my mistake: making my autonomous psychic functioning too obvious. As a result, I decided to only say, “I am sorry,” and left the remaining thought unspoken. The patient relaxed and the tension in the room began to lessen. After ten minutes of further silence, the patient said, “Well, this session has been messed up. I had so many things to say.” After a further pause, she said, “Among the various things on my mind . . .” and thus the session gradually “started.” By the time we ended, things were going pretty smoothly.

In the first vignette, the disruption was mild and was mostly caused by the inordinate depth and mistiming of my (content-wise, correct) intervention. In the second vignette, the disruption was more intense and was caused by an admixture of my natural and friendly but dynamically misattuned remark and the patient’s pre-existing paranoid attitude. The contribution of the latter pole of disruption dynamics is more clear in the following vignette. Case 3 A borderline young man in twice-weekly psychotherapy exploded with rage when I refused to comply with his demand for painkillers. In a menacing tone, he threatened to take my eyeballs out and crush them under his feet. Alarmed by his emotional flooding and rapidly disintegrating reality testing, I firmly told him to stay put in his chair. I added that if he as much as laid a finger up on me, I would terminate the treatment and never see him again. I told him that he needed someone who could listen to him peacefully, not someone who was afraid of him and that I will be afraid of him if he acted even once on his impulse to hurt me. Noticing that he was settling down, I added that the idea that he could take my eyeballs out was both unrealistic and

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In contrast to the three clinical vignettes offered so far, disruptions of therapeutic frame, at times, happen outside of clinical hours. Case 4 A thin-skinned fearful, and immensely needy, borderline young woman was in a fivetimes-a-week analysis. From time to time she felt a bit more confident of her acceptability to me. Usually this was a result of a piece of superego analysis, whereby the defensive nature of her inhibitions became more observable to her and she learnt of the childhood roots and current uses of terrifying inner injunctions. Mostly, she was afraid of overburdening me and immensely thankful for my attention. At other times, she expressed a need to see me more often, have longer sessions, meet me on demand, and so on. Five times a week for 50 min certainly did not seem enough. I encouraged her to tell me more about this. She revealed that as a child she felt horribly rejected by her mother, who sternly discouraged any physical contact between them. She sobbed. We went on in this staccato fashion. Then, one day she revealed that she had found out where I lived and had driven by to take a look at my house. I experienced mixed feelings upon hearing this. Mostly, I felt fascination at this manner of transference deepening. The link between this behavior and her childhood wishes to touch her mother was clear to me. When I brought this to her attention, she noticed the connection too. However, the material did not deepen. Inquiries regarding what fantasies she had about my house, what or who she really wanted to see, what the house stood for, how the looking at my house might have been a way of avoiding wishes to see me more fully (she was on the couch) yielded meager results. Gradually, the pattern of visiting my house became a regular one. Three, four times a week, including those on weekends, she drove by the street on which I live, slowing down as she passed my house, looking at it intently. Once in a while, from inside my house, I could see her driving by in her car. I felt intruded upon and annoyed. Listening to the reports of these visits during her sessions, I was reminded of her wanting to see me more than five times a week, for longer sessions, and on demand. I wondered if behind such coercive control lurked the fear of having “killed” me during the intervals. Or, was it a developmental need? In other words, was the patient’s wish to have more contact a defense against repressed hostility or was her going to my house an innovative way of having more sessions, without which she felt utterly disorganized? Two interventions were thus possible. One leaned towards interpreting the defensive and/or provocative actions. The other involved acknowledging the adaptive aspects of her behavior, which sought satisfaction of an ego need that I had failed to meet. I chose the latter intervention and it facilitated the progress of our work. The patient felt understood, came up with new memories, and gradually stopped driving by my house.

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This list of pained pauses (case 1), angry withdrawals (case 2), threats of violence (case 3), and stalking-like behavior (case 4) does not exhaust the manifestations of clinical disruption. Walking out in the middle of sessions, deliberate lateness, not paying bills, destroying property in the therapist’s office, and dropping out of treatment constitute other manifestations. Still more behavioral examples can be given, I am sure. What remains common in all these instances, however, is the breakdown of verbal communication and overthrow of therapeutic alliance by transference acting out.

Treatment While the technical stance vis-`a-vis disruptions has found some mention above, I now wish to spell such matters out more explicitly. My aim is to highlight five aspects of psychotherapeutic technique that deal directly with episodes of disruption. These points are to be utilized alongside the ordinary therapeutic tasks of listening with empathy and non-judgemental attitude, offering support and clarification, interpreting transferences, and formulating genetic reconstructions. Holding and containing

The term “holding environment” was coined by Winnicott in connection with the ordinary function of a mother holding her infant. Holding in this context meant “not only the actual physical holding of the infant, but also the total environmental provision prior to the concept of living with” (Winnicott, 1960; p. 43). Winnicott (1960) noted that the holding environment’s main function is “the reduction of impingements to which the infant must react with resultant annihilation of personal being” (p. 47). He came to believe that the psychotherapeutic situation should be like such a holding environment and should provide safety, security, an unhurried attitude, and containment of affects and offer an opportunity for one’s growth potential to be reactivated. Such metaphorical holding becomes even more important when the physical continuity of a session is threatened. A common situation is when a patient abruptly and angrily walks out of a session, slamming the office door behind them. Faced with such a situation, the therapist should neither stay put in their chair nor run after the patient. The former allows the patient’s “attack on the setting” (Limentani, 1989) to rupture the therapeutic connection, and exposes the patient to the humiliation of having to knock on the door should he or she return. The latter is an impingement on the patient’s autonomy, permissible only if there is a serious suicidal risk and not otherwise. Better than either of these options is walking up to the door, opening it, making sure that it stays open, and returning to one’s chair. This way the office has been “extended” to include the hallway or wherever the patient has gone.

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Assuring safety and setting limits

The therapist dealing with a truly intense disruption must also take measures to protect the physical safety of the two people involved in the transaction. Suicidal and homicidal crises (and their less malignant versions) must be handled with patience coupled with firm limit setting. A combination of empathy, resilience, and reality testing should form the mainstay of the therapist’s approach. Use of psychotropic medications employing judicious guidelines (Gorton and Akhtar, 1990) and of adjunct measures (e.g., family meetings, hospitalization) should also be considered if the patient’s regression is severe and if the disruptive behaviors are approaching dangerous limits. Naming and taming

Disruptions accompanied by emotional flooding, danger of in-session violence, and diabolical transformations of patient’s identity should be met with “re-humanizing” attempts on the therapist’s part. The therapist should appear calm, not make abrupt movements, and gently but clearly name the affect that the patient is experiencing (Katan, 1961). For instance, the therapist might say “you are really enraged,” or “you seem to be in unbelievable pain.” Such comments might appear simplistic but the fact is that they give the patient an intellectual handle at a time when his or her ego is getting overwhelmed by affect. If this does not seem sufficient to calm the patient down, the therapist might gently take the patient’s first name while talking to him or her (Volkan, 1976). Thus “reminding” the patient of who they are in reality can draw a cognitive wedge between the diabolically transformed self and the sector of sanity that still exists under such circumstances. Oscillating in accordance with the patient’s level of transferences

Most patients with severe personality disorders fluctuate between integrated and un-integrated levels of ego functioning. At the former, they appear torn and conflicted. At the latter, they seem confident and demanding. This is important to keep in mind since the therapist’s approach has to shift according to such alterations in the patient. When the patient’s transferences reflect the conflict-based sector of his or her personality, the technical approach should be one of skeptical listening, searching for concealed meanings, and interpretive interventions. But when the patient’s transferences reflect deficit-based sectors of his or her personality, the technical approach should be characterized by credulous listening, validation of the patient’s psychic reality, and affirmation interventions (Killingmo, 1989). At such moments “issues of subtle meaning, affect, and wish, are of secondary importance to the issues of internal intactness” (Greenspan, 1977, p. 387). In other words, holding, facilitating, containing, and surviving matter more at such moments than deciphering and interpreting on the analyst’s part.

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Designating these two poles of technique “maternal” and “paternal” and tracing them back to Winnicott’s and Freud’s therapeutic styles respectively, Wright (1991) declared that they “provide a point and counterpoint in analysis between two styles and two visions and neither wins the day completely” (p. 200). The therapist has to learn to oscillate between affirmative and interpretive aspects of technique and such oscillations should be in harmony with patient’s movements of regression and progression (Killingmo, 1989). Acknowledging one’s own role in precipitating a disruption

When an honest bit of soul searching on the therapist’s part reveals that he or she might have contributed to the occurrence of a disruption, this must be explicitly acknowledged and conveyed to the patient. By so doing, the therapist: (1) provides the patient with an experience of having effectively communicated his or her distress to the analyst, which results in a self-enhancing experience of efficacy; and (2) restores the patient’s experience of a positive bond with the analyst. A comment indicating one’s understanding of the patient’s suffering often leads to further progress in psychotherapy. The acknowledgment by the analyst of his having been experienced by the analysand in such a way as to trigger the disruption usually leads to a collaborative inquiry by both into the dynamic and genetic causes of the disruption. For the analysand this becomes an experience of being understood, an experience of efficacy in having an influence on the analyst, and, finally, an experience of being vitalized by the affective attunement with the analyst. (Wolf, 1995, pp. 94– 95)

While an acknowledgement of one’s lapse in empathy is often sufficient, in situations where the therapist’s “mistake” is gross, an apology might be indicated. This is a controversial matter to be sure. Goldberg (1987), in discussing the place of apology in psychoanalysis, delineates two possible stances. One stance, exemplified in the clinical material previously mentioned, emanates from the analytic perspective which suggests that, via empathic immersion, the analyst may attain an ability to see the patient’s world as he or she does and the major burden of achieving and sustaining such intersubjective agreement rests upon the analyst. In this view the failure of intersubjectivity would largely be the analyst’s responsibility and thus necessitate an apology from the analyst. The second stance, mentioned by Goldberg (1987), argues the untenability of either extreme position, concluding that while the wish to apologize may be countertransference based, it does have a place at certain times in certain treatments. Of course, the patient’s experience of the analyst’s apology needs then to be explored and handled in a relatively traditional way.

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A developmental postscript The therapist dealing with individuals prone to disruptions must remember that, developmentally speaking, disruption is not an exception but a rule. Traced through the life span, one can observe that: (1) the onset of the differentiation phase of separation–individuation disrupts the calm of symbiosis, and the rapprochement phase destabilizes the euphoric self-reliance of the practicing phase proper (Mahler et al., 1975); (2) the discovery of anatomical differences between sexes (Freud, 1925) puts an uncomfortable end to the ignorant bliss of the preceding era; (3) the beginning of adolescence (Blos, 1967; Erikson, 1950) abruptly terminates the playful equanimity of latency; and (4) the arrival of middle age, with its own characteristic psychosocial challenges (Kernberg, 1980), shakes up the hitherto coherent adulthood. What all this tells us is that psychic development continues throughout life (Pine, 1997) and occurs in a dialectics of “noisy” and “non-noisy” phases (Leaff, 1991). The former introduce new developmental tasks, and the latter synthesize and consolidate these gains. The same applies to psychotherapy. Another developmental matter is pertinent in this context. This involves the fact that the technical polarities of listening with credulousness (and responding with affirmative interventions) versus listening with skepticism (and responding with interpretive interventions) are akin to the maternal and paternal styles of relating to young children. Herzog’s (1984) elucidation of the “homeostatic” and “disruptive” attunements of parents to their growing child is especially illuminating here. Through video-monitored child-observational studies, Herzog has demonstrated that mothers usually join in with a toddler in his or her ongoing play (e.g., building a tower with wooden blocks), thus giving the child a “continuity of being” (Winnicott, 1965, p. 54), validity and harmony with the environment (“homeostatic attunement”). Fathers, on the contrary, characteristically disrupt the playing toddler’s equilibrium by cajoling him or her into joining them in a new activity (“disruptive attunement”). Homeostatic attunement has affirming qualities necessary for the sustenance and consolidation of self-experience. Disruptive attunement has enhancing qualities necessary for the broadening and deepening of self-experience. The influence of the two types of attunement is additive and contributes to a healthy self-experience. Herzog further observed that fathers distract the child from the game he or she is playing only when the mother is with the child. In her absence, and especially with younger children, fathers too start playing the child’s own game (i.e., resort to homeostatic attunement). This suggests that homeostatic attunement is an experiential prerequisite for disruptive attunement. Extrapolating these developmental observations to the clinical situation suggests the following. The analyst’s credulous listening and “affirmative” (Killingmo, 1989) interventions are akin to the maternal “homeostatic attunement” insofar as

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they too aim to validate, strengthen, and stabilize the self-experience. The analyst’s skepticism regarding the patient’s conscious material and his or her unmasking interpretive interventions seem akin to the paternal “disruptive attunement” insofar as these too cause cognitive expansion by introducing new material into the patient’s awareness. Herzog’s conclusion that homeostatic attunement is a prerequisite for the disruptive attunement also finds a parallel in the clinical situation wherein the analyst’s holding and affirmative functions must be securely in place in order for his or her interpretive efforts to be fruitful. Couched in this developmental metaphor, the analyst’s exercise of maternal functions seems to be a prerequisite for his or her exercise of paternal functions. Applied specifically to episodes of disruption, one can say that the patient’s inner sense of the therapeutic relationship must be stabilized before he or she can utilize interpretations which, by definition, bring something new to the patient’s attention and slightly destabilize him or her. The patient must be helped to regain a “safety feeling” (Sandler, 1960) before the risk of encountering the repudiated aspects of his or her self-experience. Finally, it should also be remembered that the capacity to cause a disruption might itself be a developmental advance on the part of the patient. In other words, a meek and previously un-entitled individual might begin experiencing enhanced self-esteem as a result of treatment and this, in turn, might lead to his or her making more overt attacks on the therapeutic boundaries. Winnicott’s (1956) notion that outrageousness is often a sign of unconscious hope (of finding an accepting and tolerant environment) is pertinent in this context. Case 5 A 40-year-old woman with an “as if” personality (Deutsch, 1942) was in twice-weekly psychotherapy with me. She had grown up living with rigid rules and constant efforts at appeasing others. As the treatment progressed, it became clear that her profoundly disinterested parents (and her caretakers subsequent to their death when the patient was four years old) had not imparted her any sense of confidence and healthy entitlement. Gradually, in her work with me, the patient began to experience enhanced self-esteem and to express criticism of me when it came to her mind. She liked this new found freedom very much and once, while angry with me, deliberately did not show up for our session. In light of her psychopathology, I saw this disruptive behavior as not only an ego advance on the patient’s part but also as evidence that the treatment was indeed progressing well.

Conclusion In this contribution, I have defined the concept of “disruption,” outlined its dynamics, described its manifestations, and elucidated psychotherapeutic techniques to deal with it. In doing so, I have cast my net wide and included both psychiatric and

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psychoanalytic perspectives. Moreover, in describing the dynamics of clinical disruptions, I have tried to account for variables from within the patient as well as from within the therapist. Throughout all of this, I have kept an eye on in-depth subjectivity as well as developmental prototypes. My hope is that what I have offered here will help the therapists of disruption-prone patients bear and understand clinical crises in a more meaningful way.

R E F EREN CES Akhtar, S. (1991). Three fantasies related to unresolved separation-individuation: a less recognized aspect of severe character pathology. In S. Akhtar and H. Parens (eds.) Beyond the Symbiotic Orbit: Advances in Separation-Individuation Theory. Hillsdale, NJ: The Analytic Press, pp. 261–284. Akhtar, S. (1992). Broken Structures: Severe Personality Disorders and Their Treatment. Northvale, NJ: Jason Aronson. Akhtar, S. (1995). Quest for Answers: Understanding and Treating Severe Personality Disorders. Northvale, NJ: Jason Aronson. Akhtar, S. (1998). From simplicity through contradiction to paradox: the evolving psychic reality of the borderline patient in treatment. Int J Psychoanal 79: 241–252. Akhtar, S. and Kramer, S. (1999). Beyond the parental orbit: brothers, sisters, and others. In S. Akhtar and S. Kramer (eds.) Brothers and Sisters: Developmental, Dynamic, and Technical Aspects of the Sibling Relationship. Northvale, NJ: Jason Aronson, pp. 1–24. Asch, S. (1976). Varieties of negative therapeutic reaction and problems of technique. J Am Psychoanal Assoc 24: 383–407. Balint, M. (1968). The Basic Fault. London: Tavistock. Bion, W. R. (1959). Attacks on linking. Int J Psychoanal 40: 308–315. Blos, P. (1967). The second individuation process of adolescence. Psychoanal Study Child 22: 162–186. Brenner, C. (1979). Working alliance, therapeutic alliance, and transference. J Am Psychoanal Assoc 27: 137–145. Deutsch, H. (1942). Such forms of emotional disturbance and their relationship to schizophrenia. Psychiatr Q 11: 301–321. Eidelberg, L. (1968). Encyclopedia of Psychoanalysis. New York: The Free Press. Erikson, E. (1950). Childhood and Society. New York: W. W. Norton. Freud, S. (1923). The ego and the id. Standard Edition 17: 3–68. Freud, S. (1925). Some psychical consequences of the anatomical distinction between the sexes. Standard Edition 19: 241–258. Goldberg, A. (1987). The place of apology in psychoanalysis and psychotherapy. Int Rev Psychoanal 14: 409–422. Gorton, G. and Akhtar, S. (1990). The literature of personality disorders – 1985–88: trends, issues, and controversies. Hosp Community Psychiatry 41: 39–51.

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Disruptions of psychotherapy and psychoanalysis Greenson, R. R. (1965). The working alliance and the transference neurosis. Psychoanal Q 34: 155–175. Greenspan, S. (1977). The oedipal-preoedipal dilemma: a reformulation in the light of object relations theory. Int Rev Psychoanal 4: 381–391. Grinker, R. and Werble, B. (1977). The Borderline Patient. New York: Jason Aronson. Gruenert, U. (1979). The negative therapeutic reaction as a reactivation of a disturbed process of separation in the transference. Bull Eur Psychoanal Fed 16: 5–9. Gunderson, J. (1985). Borderline Personality Disorder. Washington, D.C.: American Psychiatric Press. Herzog, J. (1984). Fathers and young children: fathering daughters and fathering sons. In J. D. Call, E. Galenson and R. Tyson (eds.) Foundations of Infant Psychiatry, Vol 2. New York: Basic Books, pp. 335–343. Hinsie, L. E. and Campbell, R. J. (1970). Psychiatric Dictionary. New York: Oxford University Press. Katan, A. (1961). Some thoughts about the role of verbalization in early childhood. Psychoanal Study Child 16: 184–193. Kernberg, O. F. (1975). Borderline Conditions and Pathological Narcissism. New York: Jason Aronson. Kernberg, O. F. (1980). Internal World and External Reality. New York: Jason Aronson. Killingmo, B. (1989). Conflict and deficit: implications for technique. Int J Psychoanal 70: 65–79. Klein, M. (1946). Notes on some schizoid mechanisms. In Envy and Gratitude and Other Works, 1946–1963. New York: The Free Press, 1975, pp. 1–24. Kohut, H. (1977). The Restoration of the Self. New York: International Universities Press. Laplanche, J. and Pontalis, J. B. (1973). The Language of Psychoanalysis. New York: W.W. Norton. Leaff, L. (1991). Separation-individuation and adolescence with special reference to character formation. In S. Akhtar and H. Parens (eds.) Beyond the Symbiotic Orbit: Advances in Separation Individuation Theory – Essays in the Honor of Selma Kramer. Hillsdale, NJ: The Analytic Press, pp. 189–208. Limentani, A. (1989). Between Freud and Klein: The Psychoanalytic Quest for Knowledge and Truth. London: Free Association Books. Mahler, M. S., Pine, F. and Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books. Miller, J. (1965). On the return of symptoms in the terminal phase of psychoanalysis. Int J Psychoanal 46: 487–501. Modell, A. (1965). On aspects of the superego’s development. Int J Psychoanal 46: 323–331. Moore, B. E. and Fine, B. D. (1968). A Glossary of Psychoanalytic Terms and Concepts. New York: American Psychoanalytic Association. Moore, B. E. and Fine, B. D. (1990). Psychoanalytic Terms and Concepts. New Haven, CT: Yale University Press. Niederland, W. G. (1981). The survivor syndrome: further observations and dimensions. J Am Psychoanal Assoc 29: 413–421. Pine, F. (1997). Diversity and Direction in Psychoanalytic Technique. New Haven, CT: Yale University Press.

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Salman Akhtar Rycroft, C. (1972). A Critical Dictionary of Psychoanalysis. London: Penguin Books. Sandler, J. (1960). The background of safety. In From Safety to Superego: Selected Papers of Joseph Sandler. New York: Guildford, 1987, pp. 1–8. Stone, M. (1990). The Borderline Syndrome. New York: McGraw-Hill. Thomae, H. and Kachele, H. (1994). Psychoanalytic Practice, Vol. 2. Northvale, NJ: Jason Aronson. Volkan, V. D. (1976). Primitive Internalized Object Relations. New York: International Universities Press. Winnicott, D. W. (1956). The antisocial tendency. In Collected Papers: Through Paediatrics to Psychoanalysis. New York: Basic Books, pp. 300–306. Winnicott, D. W. (1960). Ego dissociation in terms of true and false self. In The Maturational Processes and the Facilitating Environment. New York: International Universities Press, 1965, pp. 140–152. Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment. New York: International Universities Press. Wolf, E. S. (1995). Selfobject experience: development, psychopathology, treatment. In S. Kramer and S. Akhtar (eds.) Mahler and Kohut: Perspectives on Development, Psychopathology, and Technique. Northvale, NJ: Jason Aronson, pp. 65–96. Wright, K. (1991). Vision and Separation: Between Mother and Baby. Northvale, NJ: Jason Aronson.

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Managing suicidal crises in patients with severe personality disorders Joel Paris

The treatment of patients with severe personality disorders, particularly those who meet criteria for the category of borderline personality (BPD), is well known to be difficult and marked by multiple crises. This chapter will focus on the most common scenario, which occurs when patients threaten to kill themselves or make a suicide attempt. Suicidal crises and suicide prevention Patients with severe personality disorders make multiple suicide attempts, gestures, and threats (Soloff et al., 2000). These behaviors are often brought on by a breach in an intimate relationship (Gunderson, 2001). The most common scenario is an impulsive but non-lethal overdose, carried out in circumstances in which rescue is likely. Self-mutilation, particularly wrist-cutting, is also common in severe personality disorders (Gerson and Stanley, 2002). But this pattern should not always be considered as suicidal behavior. This behavior might have a different purpose from an overdose: instead of providing escape from a difficult situation, cutting functions as a means of regulating dysphoric affects (Brown et al., 2002; Leibenluft et al., 1987), and can take on some of the characteristics of an addiction (Linehan, 1993). Suicide attempts obviously require attention from therapists. However, it has never been shown that we can prevent patients with severe personality disorders from killing themselves. Moreover, it is very difficult to predict who is most at risk. In a population characterized by repeated suicide attempts, it is important to note that patients who make repeated attempts are statistically more at risk for completion (Zahl and Hawton, 2004). Yet only a minority will actually end their lives by suicide (Goldney, 2000). The reason is that suicide attempters and completers are, by and  C Cambridge University Press 2007

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large, two different populations (Beautrais, 2001). While about 1 in 20 people in the United States makes a suicide attempt sometime during their life, the overall ratio of attempts to completions is about 1/500 (Welch, 2001). Moreover, completers tend to be older, male, to use methods more likely to be lethal, and to die on the first attempt; attempters tend to be younger, female, to use less lethal methods, and to survive (Maris et al., 2000). It has proven difficult to predict completed suicide in any psychiatric population, and attempts to do so have been remarkably unsuccessful. Thus, two large-scale studies (Goldstein et al., 1991; Pokorny, 1983) followed populations of patients admitted to hospital to determine who eventually completed suicide. The researchers applied algorithms based on established risk factors in the literature, but failed to predict any individual case of suicide. It has long been established that some risk factors (psychiatric diagnosis, previous attempts, lack of social supports) have a statistical relationship to completion (Maris et al., 2000). But in relation to attempts, completed suicide is a much rarer event. Thus, all of these risk factors produce a large number of false positives. Similar problems limit the prediction of completed suicide in patients with severe personality disorders. In long-term follow-up studies of BPD, statistically significant relationships with risk factors have been found, including substance abuse (Stone, 1990) and previous attempts (Paris et al., 1989). However, given the number of false positives, this information could not have been used in any practical way to predict completion in individual patients. On the other hand, long-term follow-up studies have yielded important findings as to when suicide completion takes place in BPD. This diagnosis is associated with multiple attempts (Soloff et al., 2000), which are, in turn, strongly associated with the affective instability that characterizes BPD patients (Yen et al., 2004). In a 15-year follow-up of patients with BPD, Stone (1990) found that the mean age at completion was 30. In a 27-year follow-up study (Paris and Zweig-Frank, 2001), the mean age at suicide was 37, with a standard deviation of 10 years. Thus few completions occur at the point when patients are most threatening in their suicidality, i.e., in their 20s. Instead, suicide occurs later in the course of illness, generally in patients who have undergone a series of unsuccessful treatments (Paris, 2002a). Thus while most patients with severe personality disorders improve over time (Paris, 2003; Zanarini et al., 2003), suicide completion will occur in those who have failed to recover from their condition. The practical implication of these findings is that the focus of management in suicidal crises in severe personality disorders need not focus on attempting to prevent patients from committing suicide. Prevention is an impractical goal in this population, and there is no evidence that our current efforts are effective. Moreover, the patients who are most at risk for killing themselves constitute a group that differs

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in important ways from those who present in emergency rooms and clinics with threats and attempts. The setting of treatment for managing crises If suicide prevention has no documented value in patients with severe personality disorders, we must question the specific benefit of hospitalization designed to prevent patients from killing themselves. Admission to a hospital ward is a traditional approach to the problem, and many clinicians are reluctant to accept that it is of unproven value. Thus hospitalization for suicidal threats and attempts is specifically recommended by the American Psychiatric Association Guidelines for the Treatment of Borderline Personality Disorder (Oldham et al., 2001), in spite of the absence of any evidence base for this type of intervention. Hospitalization is common in patients with BPD (Hull et al., 1996), and there are a number of reasons why it is so frequently used. Perhaps the most important factor is that, in an emergency setting, clinicians worry that patients may commit suicide if sent home. Ironically, this sequence of events has never been described. (While the relationship has never been studied systematically, in nearly 40 years of practice, I cannot identify a single case where a patient with a personality disorder killed himself after being sent home from an emergency room.) The rationale for hospital admission is based on the concept that suicidal patients require “safety.” But in what way is the hospital environment truly “safe?” Suicide is not impossible on a ward, and some patients (with psychosis or melancholia) can kill themselves in spite of all precautions. Moreover, in patients with severe personality disorders, hospital wards tend to reinforce the very behavior they attempt to control. The more the patient threatens suicide, the more attention is provided by the staff, and the longer the stay in hospital will be. Patients who are afraid of discharge, having to return to a difficult life on the outside, only need to report increased suicidality in order to delay discharge. In spite of nursing procedures designed to reduce risk, such as removing sharp objects from the patient’s possession, wristslashing can escalate on a ward. This pattern can also lead to repeated hospitalizations (Paris, 2002b). There are clinical reports in the literature that patients with personality disorders may become worse in response to hospital admission (Dawson and MacMillan, 1993). Linehan (1993) has suggested wryly that if a patient must be hospitalized, the ward environment should be made as unpleasant as possible, to avoid undue gratification of the patient’s regressive and coercive tendencies. A patient who recovered from borderline personality disorder (Williams, 1998) published a brief article in Psychiatric Services describing how repetitive hospital admissions made her worse: “Do not hospitalize a person with borderline

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personality disorder for more than 48 hours. My self-destructive episodes – one leading right into another – came out only after my first and subsequent hospital admissions, after I learned the system was usually obligated to respond.” She went on to say, “When you as a service provider do not give the expected response to these threats, you’ll be accused of not caring. What you are really doing is being cruel to be kind. When my doctor wouldn’t hospitalize me, I accused him of not caring if I lived or died. He replied, referring to a cycle of repeated hospitalizations, ‘That’s not life.’ And he was 100 percent right!” (Williams, 1998, p. 174). Many experts on the treatment of personality disorders (Gunderson, 2001; Kernberg, 1997; Linehan, 1993; Livesley, 2003, Paris, 2002a) fully agree with her views. It has even been suggested that one of the few benefits of managed care in the United States is to discourage admissions of patients with severe personality disorders. Another reason for hospitalizing patients with severe personality disorders is the therapist’s fear of litigation if a suicide occurs. Even if such events are rare (albeit more common in North America than in Europe), they do occur, and when they do, they can be traumatic. However, as Gutheil (1992) has pointed out, clinicians who choose not to hospitalize patients can adequately protect themselves by keeping careful records documenting the reasons for their decision, by obtaining consultations, and by involving the family in the treatment plan. The most common reasons why patients with borderline personality disorder are hospitalized are psychotic episodes, serious suicide attempts, suicidal threats, and self-mutilation (Hull et al., 1996). In a brief psychosis, one can at least provide specific treatment (neuroleptic medication) to control symptoms. The hospitalization of a patient after a life-threatening suicide attempt may also have some value; even if no active treatment is conducted in hospital, a brief admission can provide an opportunity to assess precipitating factors and review treatment plans. The purpose of hospitalization is less clear for suicidal threats, minor overdoses, or self-mutilation. There is no specific treatment to offer on the ward that cannot be provided in another context. Often, the patient is only monitored and observed. And since outside life is entirely interrupted, patients have no opportunity to learn or practice behavioral skills. Hospitalization has also been used to carry out specialized forms of psychotherapy for patients with severe personality disorders (Kernberg, 1987). This approach died out in America with the advent of managed care. In Europe, where there are fewer restrictions on the expense of a hospital stay, the approach is still used. The concept is to provide more intensive therapy in a controlled milieu. Patients may be admitted when treatment spirals out of control and the clinician can often benefit from the help of a specialized team (Hellinga et al., 2002). However, the necessity for using full hospitalization to carry out specialized psychotherapy has not been demonstrated. These interventions can equally be carried

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out in day hospitals, as has been shown by several research groups (Bateman and Fonagy, 1999; Chiesa and Fonagy, 2002; Piper et al., 1996). Day hospitals have all the advantages of a ward (opportunity for intensive management within a structured environment) without the disadvantages of full admission (regression in patients who are cut off from their ordinary life during the course of the hospitalization). But if admission is carried out, it can generally be short, and one study has reported that patients have a better outcome if a brief hospitalization is followed by a period of day treatment (Chiesa and Fonagy, 2002). In general, when outpatient treatment of severe personality disorders goes out of control, and cannot be maintained without additional interventions, day treatment offers an evidence-based alternative. The main problem is that day hospitals tend to have waiting lists and are therefore hard to access. Moreover, many locations lack this option. This is unfortunate, given the evidence base for the effectiveness of day treatment, first developed more than 60 years ago. Many psychiatrists are also dependent on hospital beds because specialized outpatient clinics are either unavailable or have long waiting lists. Suicidal crises and chronic suicidality The key problem for the therapist treating severe personality disorders is that, above and beyond crisis episodes, patients can be chronically suicidal, sometimes for years on end (Paris, 2002b; Schwartz et al., 1974). This clinical scenario requires a different set of therapeutic principles than those applied to depressed patients who do not have personality disorders (Fine and Sansone, 1990). Kernberg (1987) suggests that chronic suicidality requires patience rather than action. He suggests (1987, p. 261) that he might state he “would feel sad but not responsible if the patient killed himself,” but would avoid unusual measures to prevent completion, and would routinely inform the family of his management plan. This rationale is similar to that of Rachlin (1984), who pointed out that attempts to save lives in suicidal patients may only succeed in depriving patients of their quality of life. Clearly, it is difficult to conduct effective therapy in a situation of constant turmoil. An excessive focus on an illusory goal of suicide prevention actually prevents therapists from doing their job. When clinicians feel forced to do almost anything to prevent completion, the therapeutic relationship becomes characterized by “coercive bondage” (Hendin, 1981), in which the patient controls the behavior of the therapist, and the quality of the patient’s life becomes compromised by this concern. Ultimately, treatment has to help patients deal with real life issues. When clinicians spend too much time worrying about suicide completion, this process becomes derailed. Maltsbergber (1994) has described the acceptance of chronic

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suicidality as a “calculated risk,” although we do not really know whether a significant risk is involved. In any case, therapists should focus less on responding to threats and more on understanding the distress that lies behind them, while refocusing the patient to work on resolving life problems. An approach to the management of crises in severe personality disorders There is now evidence for the efficacy of two specific psychotherapeutic methods for patients with severe personality disorders: Dialectical Behavior Therapy (DBT; Linehan, 1993), and Mentalization-Based Treatment (MBT; Bateman and Fonagy, 2004). Both are effective in reducing self-mutilation and suicide attempts. DBT is conducted in an outpatient setting and Linehan (1993) has specifically advised against hospitalization. MBT, which was originally tested in a day hospital setting, has recently undergone trials in outpatient clinics (Fonagy, 2004). Other psychotherapeutic methods, including schema therapy (Young, 1999) and Transference-Focused Psychotherapy (TFP; Yeomans et al., 2002), are also undergoing clinical trials in outpatient settings. The approach being recommended here is consistent with the concepts behind these evidence-based approaches, as well as with the views of other experienced therapists (Kernberg, 1987; Livesley, 2003; Gunderson, 2001). The key principle in managing crises is to maintain the overall structure of treatment, however frightening the patient’s suicidal threats. The reason is that psychotherapy needs to provide a predictable structure for these patients. No matter how strongly that structure is challenged, it needs to be retained. For example, providing extra sessions or telephone contact in a crisis changes the structure of therapy and can therefore have negative consequences. This principle does not apply to Linehan’s (1993) use of telephone contact, since the availability of the therapist is built in from the beginning. Moreover, the purpose of telephone calls in DBT is different, in that it is brief, mainly provides coaching, and avoids reinforcement of suicidality. Similarly, one should be cautious about responding to a crisis by changing a patient’s medication. While psychopharmacology has its role in the treatment of severe personality disorders, the evidence suggests that most of the drugs that have been used (specific serotonin-reuptake inhibitors, low-dose neuroleptics, and mood stabilizers) have ameliorative properties, but do not lead to remission of the underlying disorder (Soloff, 2000). The best demonstrated effect of these agents is a reduction in impulsivity (Paris, 2003). Instead, suicidal crises should be dealt with by seeing suicidality, like any other symptom, as a phenomenon to be understood, and by developing strategies to deal with it. Linehan (1993) applies the principle of “behavioral analysis” to suicidal

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ideas and behavior, which focuses on explaining the circumstances in which they arise, and developing alternative solutions to the life problems that underlie these symptoms. Similar approaches have been described by Gunderson (2001) and Livesley (2003). Again, it is useful to emphasize that most patients with severe personality disorders show a gradual pattern of recovery, that most suicides do not take place in a crisis situation, and that psychotherapy has been shown to be effective in many if not most of these cases. For these reasons, therapists should not be unduly anxious about the outcome of crises, and should maintain a position of calm that provides a model for patients who are overwhelmed by their own intense affective states. Crises are part and parcel of the psychopathology of severe personality disorders. They are “part of the territory,” and clinicians should expect recurrent episodes of this kind in this population.

R EF EREN CES Bateman, A. and Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 156: 1563–1569. Bateman, A. and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford: Oxford University Press. Beautrais, A. L. (2001). Suicides and serious suicide attempts: two populations or one? Psychol Med 31: 837–845. Brown, M. Z., Comtois, K. A. and Linehan, M. M. (2002). Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol 111: 198–202. Chiesa, M. and Fonagy, P. (2003). Psychosocial treatment for severe personality disorder: 36-month follow-up. Br J Psychiatry 183: 356–362. Dawson, D. and MacMillan, H. L. (1993). Relationship Management of the Borderline Patient: From Understanding to Treatment. New York: Brunner/Mazel. Fine, M. A. and Sansone, R. A. (1990). Dilemmas in the management of suicidal behavior in individuals with borderline personality disorder. Am J Psychother 44: 160–171. Fonagy, P. (2004). An update of BPD treatment evaluation research in England. Presented to the NIMH International Think Tank for the More Effective Treatment of Borderline Personality Disorder. Linthioum, MD, July, 2004. Gerson, J. and Stanley, B. (2002). Suicidal and self-injurious behavior in personality disorder: controversies and treatment directions. Curr Psychiatry Reports 4: 30–38. Goldney, R. D. (2000). Prediction of suicide and attempted suicide. In K. Hawton, K. van Heeringen (eds.) The International Handbook of Suicide and Attempted Suicide. New York: John Wiley, pp. 585–596.

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Joel Paris Goldstein, R. B., Black, D. W., Nasrallah, A. and Winokur, G. (1991). The prediction of suicide. Arch Gen Psychiatry 48: 418–422. Gunderson, J. G. (2001). Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Press. Gutheil, T. G. (1992). Suicide and suit: liability after self-destruction. In D. Jacobs (ed.) Suicide and Clinical Practice. Washington, DC: American Psychiatric Press, pp. 147–167. Hellinga, G., Van Luyn, B. and Dalewijk, H.-J. (eds.) (2002). Personalities: Master Clinicians Confront the Treatment of Borderline Personality Disorder. Amsterdam: Boom. Hendin, H. (1981). Psychotherapy and suicide. Am J Psychother 35: 469–480. Hull, J. W., Yeomans, F., Clarkin, J., Li, C. and Goodman, G. (1996). Factors associated with multiple hospitalizations of patients with borderline personality disorder. Psychiatric Services 47: 638–641. Kernberg, O. F. (1987). Diagnosis and clinical management of suicidal potential in borderline patients. In J. S. Grotstein and M. F. Soloman (eds.) The Borderline Patient: Emerging Concepts in Diagnosis, Psychodynamics and Treatment. New York: Psychoanalytic Inquiry Book Series, pp. 69–80. Leibenluft, E., Gardner, D. L. and Cowdry, R. W. (1987). The inner experience of the borderline self-mutilator. J Pers Disord 1: 317–324. Linehan, M. M. (1993). Cognitive Behavioral Therapy of Borderline Personality Disorder. New York: Guilford. Livesley, W. J. (2003). The Practical Management of Personality Disorder. New York: Guilford Press. Maltsberger, J. T. (1994). Calculated risk in the treatment of intractably suicidal patients. Psychiatry 57: 199–212. Maris, R. W., Berman, A. L. and Silverman, M. M. (2000). Comprehensive Textbook of Suicidology. New York: Guilford Press. Oldham, J. M., Gabbard, G. O., Goin, M. K. et al. (2001). Practice guideline for the treatment of borderline personality disorder. Am J Psychiatry Suppl 158: 1–52. Paris, J. (2002a). Implications of long-term outcome research for the management of borderline personality disorder. Harvard Rev Psychiatry 10: 315–323. Paris, J. (2002b). Chronic suicidality in borderline personality disorder. Psychiatric Services 53: 738–742. Paris, J. (2003). Personality Disorders Over Time. Washington, DC: American Psychiatric Press. Paris, J., Nowlis, D. and Brown, R. (1989). Predictors of suicide in borderline personality disorder. Can J Psychiatry 34: 8–9. Paris, J. and Zweig-Frank, H. (2001). A twenty-seven year follow-up of borderline patients. Compr Psychiatry 42: 482–487. Piper, W. E., Rosie, J. S. and Joyce, A. S. (1996). Time-Limited Day Treatment for Personality Disorders: Integration of Research and Practice in a Group Program. Washington DC, American Psychological Association. Pokorny, A. D. (l983). Prediction of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40: 249–257. Rachlin, S. (1984). Double jeopardy: suicide and malpractice. Gen Hosp Psychiatry 6: 302– 307.

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Managing suicidal crises in severe personality disorder Schwartz, D. A., Flinn, D. E. and Slawson, P. F. (1974). Treatment of the suicidal character. Am J Psychother 28: 194–207. Soloff, P. (2000). Psychopharmacological treatment of borderline personality disorder. Psychiatr Clin North Am 23: 169–192. Soloff, P. H., Lynch, K. G., Kelly, T. M., Malone, K. M. and Mann, J. J. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry 157: 601–608. Stone, M. H. (1990). The Fate of Borderline Patients. New York: Guilford Press. Welch, S. S. (2001). A review of the literature on the epidemiology of parasuicide in the general population. Psychiatric Services 52: 368–375. Williams, L. (1998). A “classic” case of borderline personality disorder. Psychiatric Services 49: 173–174. Yen, S., Shea, M. T., Sanislow, C. A., et al. (2004). Borderline personality disorder criteria associated with prospectively observed suicidal behavior. Am J Psychiatry 161: 1296–1298. Yeomans, F., Clarkin, J. F. and Kernberg, D. F. (2002). A Primer of Transference-Based Psychotherapy. Northvale, NJ: Jason Aronson. Young, J. E. (1999). Cognitive Therapy for Personality Disorders: A Schema-Focused Approach, 3rd edn. Sarasota, FL: Professional Resource Press. Zahl, D. L., Hawton, K. (2004). Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11,583 patients. Br J Psychiatry 185: 70–75. Zanarini, M. C., Frankenburg, F. R., Hennen, J. and Silk, K. R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 160: 274–283.

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Borderline personality disorder, day hospitals, and mentalization Anthony W. Bateman and Peter Fonagy

Borderline personality disorder (BPD) is an intriguing condition and a great deal of theory has been applied to understanding its development and its clinical characteristics. Less consideration has been given to research into practical treatment although acronymic approaches with some effectiveness have begun to flourish over the past few years. There are now DBT (Dialectical Behavior Therapy) (Linehan, 1993), MBT (Mentalization-Based Therapy) (Bateman and Fonagy, 2004b), CAT (Cognitive Analytic Therapy) (Ryle, 1997), CBT (Cognitive Behavioral Therapy) (Davidson, 2000), and SFT (Schema-Focused Therapy) (Young, 1990). Others may follow (Gunderson, 2001). The profile of the disorder has increased both within and without mental health services as a result of the advent of moderately effective treatments. Publication of evidence-based treatment guidelines in the USA raised the profile of BPD further and even though some have claimed the recommendations were premature (Tyrer, 2002) there is little doubt that they marked a turning point in mental health services, placing BPD further up the mental health agenda of priorities. A strategic review of treatment of personality disorder by the Department of Health in the UK (DoH, 2003) also formally marked the end of a neglectful era in the UK. A sad era during which individuals with a primary diagnosis of BPD received inappropriate, inadequate, and reluctant care from disorganized services; a haphazard delivery of services undoubtedly made worse by the curious mixture of reasonable and irrational conduct so common in individuals with severe personality disorders which itself generates confusion amongst those working to help them. Whilst some investigation has gone into theory and models of treatment, less thought has been applied to the context in which treatments are offered. All treatments can be applied within different environments such as inpatient wards, day hospitals, outpatient clinics, therapeutic hostels, or even the patient’s own home and yet we know very little about the effect of the context of a treatment on its  C Cambridge University Press 2007

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efficacy. Further we have almost no knowledge about who should be treated where and by whom even though it is well known that patients with BPD are heavily influenced by their environment and especially by social circumstances and life events. The purpose of this chapter is to consider the role of day hospitals as the context for treatment of BPD, to emphasize that the day hospital is a background of treatment and not a treatment itself, and to outline some of the features of day hospitals and treatments applied within them that might be important in maximizing positive outcomes for patients with BPD. But first, why bother to treat BPD particularly since there is increasing evidence that the natural course of the disorder suggests improvement over time?

Epidemiology Borderline personality disorder is an important health issue for a number of reasons. First BPD is a common condition with a prevalence of between 0.2% and 1.8% of the general population (Swartz et al., 1990). Second, patients are heavy users of mental health facilities and social services because of their impulsive behavior and considerable desperation and distress (Zanarini et al., 2004). Third, they have an ability to engage practitioners in attempts to help them even though those interactions may at times be detrimental. Finally, the association of BPD with suicide attempts and successful suicide (Paris and Zweig-Frank, 2001) means that there is an urgency to find appropriate interventions if the sad and needless loss of life in young people is to be reduced. Most epidemiological studies originate from North America and the situation may be different elsewhere. The most reliable study of the prevalence of the disorder outside the USA in a community sample conducted in Oslo (Torgersen et al., 2001) suggested that the prevalence of BPD was not as frequent as commonly assumed, with only 0.7% of patients being diagnosed as borderline from a representative community sample. The subjective experience of practitioners that BPD is a common disorder might therefore be an artifact of the demand that borderline patients place upon them rather than the actual number within society. But prevalence rates increase if patients within the mental health system are sampled, with the highest rates being found in those patients requiring the most intensive level of care – outpatient rates range 8%–11%; inpatient rates, 14%–20%; and forensic services, 60%–80%. In a Dutch forensic psychiatric hospital 80% of patients fulfilled criteria for at least one personality disorder, with paranoid, antisocial, and borderline being the most common (Ruiter and Greeven, 2000). Similar rates have been found in England and Sweden (Blackburn et al., 1990), with the most common being borderline and antisocial personality disorder (Dolan and Coid, 1993).

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Severity The prevalence pattern described above reflects the considerable heterogeneity among patients receiving the diagnosis BPD. The question of severity is of considerable importance for the clinician although there is no agreement about its definition in BPD any more than there is for other mental illnesses. A number of approaches have been used. Severity may be defined according to which criteria of the nine criteria of BPD that the patient fulfils. Suicide attempts and self-mutilation are regarded as severe symptoms, often being targets of specific treatment interventions and measures of treatment effect. Grilo et al. (2001) found that 59% of 240 BPD patients in the American colloborative longitudinal personality disorder study fulfilled this criterion. Severity may also be related to the total number of BPD criteria that are fulfilled, partly because total number is positively correlated to the number of other PD criteria and other PD diagnoses. Tyrer and Stein (1993) suggested that severity could be based on the level of complexity of a patient, which is broadly indicated by the number of different personality criteria used in the categorical diagnostic systems met by the patient. For example, a patient who meets subthreshold criteria for one of several personality disorders would be considered to have personality difficulty. This would change to simple personality disorder if criteria for one or more personality disorders within the same cluster were met, and to complex personality disorder when criteria for one or more personality disorders within more than one cluster were met. Severe personality disorder would be reserved only for those patients who met above-threshold criteria for a number of different personality disorders in more than one cluster and also created severe disruption to themselves and to many in society.

Severity and context of treatment Assessing the level of severity, including risk assessment, is of course of paramount importance for treatment planning. Common sense suggests that the more severe the patient, the more he or she may be in need of a comprehensive treatment program. But common sense is notoriously wrong. The core problems of borderline patients present within intimate interpersonal contexts and increasing the intensity of treatment may stimulate rather than ameliorate the underlying difficulties. So a less intensive approach, enabling the patient to titrate the emotional intensity, may be more appropriate. We have some evidence for this. Chiesa and colleagues (Chiesa and Fonagy, 2000; Chiesa et al., 2004) found that briefer periods of hospitalization were more efficacious than longer ones in a mixed group of patients with personality disorder. They studied the relative effectiveness of

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three psychodynamically oriented treatment models for a mixed group of personality disorders: (1) long-term residential treatment using a therapeutic community approach; (2) briefer inpatient treatment followed by community-based dynamic therapy (step-down program); and (3) general community psychiatric treatment. To some extent these three treatment programs represent different levels of intensity, with the community psychiatric treatment being the least intensive. Initial results suggested that brief inpatient therapeutic community treatment followed by outpatient dynamic therapy was more cost-effective and more effective than both long-term residential therapeutic community treatment and general psychiatric treatment in the community on most measures, including self-harm, attempted suicide, and readmission rates to general psychiatric admission wards (Chiesa et al., 2002b). Follow-up at 36 months confirmed that patients in the step-down program continued to show significantly greater improvement than the inpatient group on social adjustment and global assessment of mental health. In addition they were found to self-mutilate, attempt suicide, and be readmitted significantly less at 24- and 36-month follow-up (Chiesa and Fonagy, 2003). These differences were maintained at the 72 months follow-up. We also have some evidence to suggest that severity does not determine the context of treatment despite a prevalent idea that the most severe patients are referred to specialist inpatient units and the less severe are treated elsewhere. In a comparative study (Chiesa et al., 2002a) we aimed (1) to ascertain whether a relationship exists between different treatment programs and settings for personality disorder and patient characteristics; (2) to give an indication of treatment effects in three personality-disordered populations admitted to different treatment contexts; and (3) to compare costs in relation to outcomes. We collected and compared three samples from one inpatient site (Cassel in England) and two day hospitals (Halliwick in England and Ulleval in Norway) on a number of demographic, diagnostic, and other key clinical variables. Outcome in the areas of symptom severity (Symptom Check-List-90-R) and social adaptation (Social Adjustment Scale) was evaluated by comparing admission with discharge scores. Treatment costs for each sample were also estimated and compared. Significant differences were found on most baseline variables across the three sites. In general with regard to severity of psychopathology the Halliwick sample was the most disturbed, Ulleval the least, with Cassel somewhat in between. No significant differences in improvement were found amongst the three sites, but treatment costs were considerably higher at Cassel than in the two day-centers. The differences found in the three samples bore no clear relationship to the context of treatment. These results suggest that referral of personality disorder for inpatient or day hospital treatment is less influenced by the severity of the problem than had been previously supposed and may depend more on the availability of the treatment facility.

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All these data suggest that a program of moderate intensity may be optimal for some patients with severe personality disorder although it is not clear exactly what profile those patients should have if treatment is to be optimally effective. A day hospital is placed in terms of intensity between inpatient and outpatient treatment and may be an ideal context in which to balance safety and risk and support whilst maintaining patient responsibility without removing patients from their own normal social supports and detaching them from their community base. It is a context which is neither too much nor too little and may be in less danger of stimulating iatrogenic effects than more intensive treatment contexts.

Some common features of day hospital treatments Day hospitals use complex programs which share certain common organizational features. They offer a high level of structure and tend to be consistent, to demonstrate theoretical coherence, to take into account the problem of constructive relationships including the formation of a positive engagement with the therapist and the team, to offer flexibility, to take an individualized approach to care, and to be well integrated with other services available to the patient. In effect, all treatment models function within a similar framework irrespective of their underlying theoretical and clinical techniques and positive outcomes may be associated with these common features more than specific therapy techniques (Bateman and Fonagy, 2000). Even models taking a different theoretical and clinical approach demonstrate overlapping features; namely, careful development of a therapeutic milieu, affect and emotional focus team work, and a mix of individual and group psychotherapy.

Milieu Day hospital treatment programs take place within a context in which a group of patients come together with a common purpose. The atmosphere that is created, the ambiance that greets people, the character of the building, and the attitudes of staff need to be conducive to the treatment orientation and focus. This is the milieu. At the extreme it becomes a treatment method in its own right and is named a therapeutic community (TC) whilst others organize the milieu in keeping with their model. Behaviorally oriented programs develop a behaviorally responsive milieu continually looking at behaviors within the system (Simpson et al., 1998). Dynamic programs develop a milieu that encourages thought over action, concern for self and other, understanding rather than dismissal, and containment without removal of responsibility. Whatever its focus, the milieu should establish an environment that contains strong feelings and fears of abandonment without excessive protection

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and without overstepping appropriate therapeutic boundaries to become overpermissive. Affect focus Everyone is agreed that borderline patients have difficulties in modulation of affect, which interfere seriously with interpersonal interactions and so treatment needs to target this aspect of emotional life. Day hospital treatment using DBT specifically focuses on emotional regulation in highly structured skills-based groups (Simpson et al., 1998). Educational packages are provided, practice sessions scheduled, and homework provided. Dynamically informed programs use process-based groups, in which affects and emotional regulation are targeted by continually clarifying and naming feelings, understanding their immediate precipitant within present circumstances, and placing them in the context of previous and present relationships (Bateman and Fonagy, 2004b). Individual and group psychotherapy The combined use of group and individual psychotherapy is not universal in treatment programs. Many day hospitals rely solely on groups as the vehicle within which treatment takes place. Interaction within groups can easily bewilder borderline patients as their mind tries to interact with a number of other minds simultaneously. This can be counteracted by structuring of groups. “Task” orientated and psychoeducation groups may be useful to give a focus that distracts from the interpersonal context but, in the end, the borderline patient has to manage complex interpersonal situations if he or she is to negotiate relationships within the world outside treatment. Consequently most day hospital programs use a mix of structured and unstructured groups, with the latter focusing on patient relationships within a group. Unstructured groups can create mindless confusion as the anxieties of patients increase and the perplexity leads to panic which might account for the high drop-out rate from some groups. We therefore recommend the addition of an individual session to programs. The addition of an individual session may enable the patients to consider themselves and their behavior within a group from a safe distance and in doing so help them to understand themselves better within social situations and so remain in the group. This structure to treatment using individual and group psychotherapy allows therapists to link different aspects of treatment and to insist that the patient considers his or her mind states in different contexts and at different times – “what was going on in me that meant I behaved like that then?” In effect the use of individual and group psychotherapy is a potent organizational element through which to

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promote what we have called mentalization and there is some research evidence to suggest that all day hospital programs must be structured to promote mentalization whatever their treatment orientation. Research and day hospital treatment It is surprising that, until the 1990s, little attention was given to research into day (or partial) hospital treatment of personality disorder given its potential as a context within which to treat some of the more severe borderline patients. In some early research Dick and Woof (1986), using a program of analytic group psychotherapy and structured group psychotherapy, found that after 12 weeks of treatment patients suffering from neurotic problems showed considerable change in self-satisfaction and reduced their dependence on psychiatric services. A small subgroup diagnosed retrospectively as borderline personality disorder increased their use of services, possibly indicating that longer term treatment is necessary to effect change in personality disorder. Tyrer et al. (1987) found no difference in outcome between outpatient and day-patient care for patients with neurotic disorders suggesting that day hospital treatment should be reserved for those patients with chronic disorders or in need of inpatient care. Many personality-disordered patients fulfil both criteria. During the 1990s many influential studies came from a well-established group in Norway. Vaglum et al. (1990) and Karterud et al. (1992) studied 97 patients prospectively, many with personality disorder, treated in a psychodynamically orientated day hospital of whom 76% had an Axis II DSM-III-R diagnosis. The program was 5 days per week, 7 h per day, and consisted of dynamic, cognitive, and expressive therapy. Primary outcome measures were SCL-90 and the Health Sickness Rating Scale. After a mean treatment time of nearly 6 months, symptom outcome was very good for patients with Axis 1 disorders only, good for Cluster C personality disorders, modest for borderline patients, and very modest for schizotypal patients. They concluded that the containing capacity of a day hospital therapeutic community is substantial and that it may reduce the need for inpatient treatment. The 3-year follow-up showed that the gains were maintained but borderline patients, along with schizotypal personality disorder patients, failed to show improvement in social functioning. Gradually the Norwegian network of day hospitals have developed an evidencebased treatment, which combines a time-limited (18 weeks) intensive, day hospital program aimed at symptom reduction, establishing a therapeutic alliance, and motivating patients to attend a follow-on program of outpatient group analytic therapy for 1.5 h per week (maximum 3.5 years) aimed at rehabilitative change. No individual therapy is offered. In their initial study (Wilberg et al., 1998b)

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183 patients were assessed at admission and discharge for symptoms, interpersonal function, and global assessment of functioning (GAF). Seventy-seven percent of patients completed the day treatment program showing improvement in all areas measured, with effect sizes in the medium to high range. At 1-year follow-up, 96 patients completed a questionnaire covering social adaptation and clinical information and participated in a telephone interview with a clinician (Wilberg et al., 1999). Improvements were maintained: 74% of treatment completers improved clinically with 64% of completers continuing in the outpatient group program. Lack of improvement was most strongly predicted by the expression of suicidal thoughts during treatment. A further paper (Wilberg et al., 1998a) underscores the importance of patient participation in the follow-on program. In a comparative study, 12 borderline patients who participated in day treatment and subsequent outpatient group psychotherapy were contrasted with 31 who engaged in the same day treatment but did not continue in the follow-up groups. At an average of 34 months of follow-up patients who participated in outpatient group psychotherapy had a lower level of symptoms, a reduced rate of re-hospitalization and suicide attempts, and a higher rate of remission from substance-misuse disorders. They argue that this indicates a combined model of day and outpatient treatment may be favorable for selected patients with BPD. The Norwegian group have also demonstrated that day treatment programs for PD are generalizable to settings other than University research centers. All patients (n = 1244) consecutively admitted to eight different treatment centers in the Norwegian Network of Psychotherapeutic Day Hospitals were screened with the structured clinical interview for DSM-IV Axis II disorders (SCID-II). In total, 1010 patients were diagnosed as having PD, with avoidant, borderline, personality disorder not otherwise specified (PD NOS), and paranoid being the most frequent. Outcome, as assessed on symptom measures, Quality of Life, work functioning, and parasuicidal behavior, was best for BPD, Cluster C patients and PD NOS, and poorer for Cluster A patients. High dosage of treatment appeared to give no better outcome than low treatment dosage (10 h per week) and the University unit did no better than units at local hospitals or mental health centers (Karterud et al., 2003). Another active research group, based in Canada, conducted one of the few controlled trials of day treatment reported in the literature. In a prospective study using a randomized design of treatment-versus-control (delayed treatment), Piper et al. (1993) found significant treatment effects of 18 weeks of day hospital treatment for patients with both affective disorder and long-standing personality disorder. Interpersonal functioning, symptoms, self-esteem, life satisfaction, and defensive functioning all improved after 4 months of treatment when compared with the control group and gains were maintained at the 8-month follow-up. The day hospital program is described in detail by Piper et al. (1996).

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The same group have investigated which patients are most likely to benefit from day hospital treatment. This is of considerable clinical importance because it would allow clinicians to place patients in an appropriate treatment context. Using the patients of the original trial, a sample of 60 patients from the treatment condition was contrasted with 39 from the delayed treatment arm on a number of predictor variables. Age, marital status, and quality of object relations (QOR) related directly to remaining in the treatment program. A history of long-lasting relationships, being older, and being married were related directly to completing the program. But the interaction of these factors was complicated. Marriage contributed positively in patients with low-level QOR whereas at high-level QOR it made no difference. Personality disorder itself was inversely related to outcome but the effect of PD was dependent on QOR. At a low level of QOR PD made no difference but at high levels of QOR PD had a negative influence on outcome. A further variable, named psychological mindedness (PM) and defined as the ability to identify dynamic components of relationships and relate them to a person’s difficulties, was related directly to a favorable outcome on general symptoms and social adjustment. Overall the strongest predictive factors were the patient’s personality characteristics as measured by PM and QOR. There was an interaction between these two: at low levels of QOR, PM had a positive effect on outcome but at higher levels it made little difference. This result has been partially confirmed in a study of 102 patients of whom 72% were diagnosed with personality disorder. Completers of treatment had higher psychological mindedness than non-completers and the presence of PM was of greater importance for those patients with a chronic psychiatric history. Further investigation of the treatment process produced more intriguing results. A process variable defined as therapeutic “work” was represented by: (1) patients’ self-rating, (2) others’ rating of the patient, (3) therapists’ rating of patient, and (4) patients’ rating of other patients. Each of the “work” variables was related positively to outcome, which makes clinical sense to the extent that those patients who participate more and work harder gain the most benefit. But interestingly there was an interaction between the “work” variable and PM. For patients with high PM the perception of other patients’ work had little effect on outcome, but for patients with low PM perception of other patients’ work was directly related to favorable outcome. Perceiving others as working may compensate for low PM and such patients may even be more dependent on others’ perceptions of them. Piper and colleagues have speculated that other patients in a group may act as an auxiliary ego for patients with low-level PM and become their psychological mind, which allows them to remain in treatment and perhaps gradually develop their own PM. Further work suggested that the overall perception by the patient of a supportive milieu environment encouraging emotional expression may also be important for change. Again, this has been partially confirmed by a study investigating outcome in

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a day hospital for a group of personality-disordered patients treated in large-group psychotherapy with small-group expressive therapy. Dazord and colleagues (Dazord et al., 1997) found that patient commitment to the large group was associated with positive symptom change. As the research evidence discussed above suggests, it is the perceptions and understanding that PD patients have about their own level of therapeutic work and that of others which may be a determining factor of outcome. This idea is in keeping with our concept of mentalization, which we have developed into a practical application as Mentalization-Based Treatment (MBT). Our original treatment program for BPD was applied in a day hospital setting and a randomized controlled trial showed reasonable effectiveness. A further application is being studied in an outpatient context in a randomized controlled trial currently underway. Our initial study (Bateman and Fonagy, 1999) compared the effectiveness of a psychoanalytically oriented day hospital program using mentalization techniques with routine general psychiatric care for patients with BPD. Treatment took place within a routine clinical service and was implemented by mental health professionals without full psychotherapy training who were offered expert supervision. The results revealed that patients in the day hospital program showed a statistically significant decrease on all measures, in contrast to the control group which showed limited change or deterioration over the same period. Improvement in depressive symptoms, a decrease in suicidal and self-mutilatory acts, reduced inpatient days and better social and interpersonal function began after 6 months and continued to the end of treatment at 18 months. Given our opinion that relatively well-structured treatments are more effective than poorly organized interventions (Bateman and Fonagy, 2000), it can be argued that it is not surprising that the carefully ordered and well-supervised MBT was more effective than general psychiatric care, but if structure itself were the cause of the gains, the gains would be likely to be short-lived. So, because of the long duration of personality disorder, our next question was whether the substantial gains made by patients following treatment in the program, when compared with patients treated with standard psychiatric care, were maintained during 18 months of follow-up. The 44 patients who participated in the original study were assessed at 3-monthly intervals after completion of the trial (Bateman and Fonagy, 2001). We continued the same battery of outcome measures. Results demonstrated that patients who had received day hospital treatment not only maintained their substantial gains, but also showed statistically significant continued improvement on most measures, in contrast to the control group of patients who showed only limited change during the same period. The continued improvement in social and interpersonal function suggests that longer term rehabilitative changes were stimulated.

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Finally, we made an attempt to assess health care costs associated with day hospital treatment compared to treatment within general psychiatric services (Bateman and Fonagy, 2003). Health care utilization by all patients who participated in the trial was assessed using information from case notes and service providers. Costs were compared 6 months prior to treatment, during 18 months of treatment and after 18 months of follow-up. There were no cost differences between the groups during pre-treatment or treatment phases. During the treatment period the costs of PH treatment were offset by less psychiatric inpatient care and reduced emergency room treatment. The trend for costs to decrease in the experimental group during follow-up was not apparent in the control group suggesting that specialist day hospital treatment for BPD is no more expensive than general psychiatric care and leads to considerable cost-savings after the completion of 18 months of treatment. Whilst our treatment program takes mentalization as its focus we are concerned not to promote MBT as a new therapy but wish for it to be seen as an intrinsic aspect of all therapies which might increase the efficacy of any given therapy if emphasized more within the framework of that therapy. So what is mentalization and why do we consider it a universal aspect of therapies? Mentalization Mentalizing entails making sense of the actions of oneself and others on the basis of intentional mental states, such as desires, feelings, and beliefs. It involves the recognition that what is in the mind is in the mind and reflects knowledge of one’s own and others’ mental states as mental states. In effect, mentalizing refers to making sense of each other and ourselves, implicitly and explicitly in terms of subjective states and mental processes. It is a capacity that is acquired gradually over the first few years of life in the context of safe and secure child–caregiver relationships. Consequently there is ample opportunity for the process to be disrupted. Our premise is that unstable or reduced mentalizing capacity is a core feature of BPD and, as such, to be successful any treatment must have mentalization as its focus or at the very least stimulate development of mentalizing as an epiphenomenon. The day hospital environment is ideal for this purpose. All group activity encourages the interaction between patients and a focus on understanding oneself and others within different contexts is a primary concern of most day hospital programs. We have discussed our developmental model of BPD in detail elsewhere (Bateman and Fonagy, 2004a; Fonagy et al., 2002; Fonagy et al., 2003). Essentially it is focused around the development of the social affiliative system which we consider to be driving the many higher-order social cognitive functions that underpin interpersonal interaction, specifically in an attachment context. We considered four of these to be of primary importance – affect representation and, related to this, affect

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regulation; attentional control, also with strong links to the regulation of affect; the dual arousal system involved in maintaining an appropriate balance between mental functions undertaken by the anterior and posterior portions of the brain; and finally mentalization, a system for interpersonal understanding within the attachment context. We suggest that these four mechanisms, including mentalizing, are in place normally to control or obscure the potential for a much more primitive form of subjectivity. This form of subjectivity is dominated by modes of representation of internal states and the relationship between internal and external, which are observable in the mental functioning of young children. These processes, in combination with the profound disorganization of self-structure, explain many facets of borderline personality functioning. We do not attribute a central role to trauma, although we expect that, in individuals made vulnerable by early inadequate mirroring and disorganized attachment to highly stressful psychosocial experiences in an attachment context, trauma will play a key role in both shaping the pathology and directly causing it by undermining the capacity for mentalization. We see this capacity as having the power to hold back modes of primitive mental functioning in those who were subjected to the same kinds of experience but who suffered little or no adverse effects. It makes conceptual sense, therefore, that mentalizing should be a focus for therapeutic intervention if we are to help borderline patients bring primitive modes of mental functioning under better regulation and control. Mentalizing as the key to successful treatment It follows from the developmental view outlined above that the recovery of mentalizing capacity in the context of attachment relationships must be a primary objective of all psychosocial treatments for BPD. But we suggest that patients with BPD are particularly vulnerable to the side-effects of psychotherapeutic treatments that activate the attachment system. Yet without activation of the attachment system borderline patients will never develop a capacity to function psychologically in the context of interpersonal relationships, which is at the core of their problems. So, the psychiatrist or other mental health professional must tread a precarious path between stimulating a patient’s attachment and involvement with treatment whilst helping him or her to maintain mentalization. Similarly the context of treatment must provide the same line between the Scylla of over-stimulation of the emotional life and the Charybdis of inadequate arousal of the patient’s underlying problems. Too much and the patient will decompensate and leave treatment out of excess anxiety; too little and the patient will manage problems intellectually without actual emotional involvement. The day hospital is an excellent environment in which to balance these features by combining groups aimed to promote

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emotional understanding of interpersonal relationships with groups aimed to tackle areas of difficulty from a pragmatic, practical perspective. Encouraging exploration and identification of emotions within multiple contexts particularly interpersonal ones, i.e., in cognitive, expressive, and analytic groups, and by helping the patient to establish meaningful internal representations whilst avoiding premature conscious and unconscious explanations is the key to successful treatment. Overall we believe that treatment will only be effective to the extent that it is able to enhance the patient’s mentalizing capacities without generating too many negative iatrogenic effects as it stimulates the attachment system. The day hospital milieu is neither too much nor too little and we argue that a mentalizing milieu is the essential ingredient for all treatment models used in a day hospital context if optimal outcomes are to be fostered. Mentalization: the common theme in psychotherapeutic approaches to borderline personality disorder and the key element of the treatment milieu The focus of different approaches to BPD – behavioral, cognitive, dynamic – is unique. But the approaches share many features. This is perhaps inevitable since all aim to address a common set of problems, the challenges of offering a psychosocial therapy to a group of individuals characterized by the remarkable turbulence of their interpersonal relationships. It is not surprising, then, that the establishment of reasonable relationship processes in the therapeutic context is in the foreground of most approaches. While it is relatively easy to discuss this topic under the heading of non-specific factors in psychological therapy, and there can be no doubt that the provision of warmth, acceptance, and a supportive environment contributes to the effectiveness of all forms of psychotherapy, we believe that it is desirable and possible to be far more precise about the specific aspects of relationship processes that are therapeutic for individuals with BPD. It is the guiding construct of our therapeutic approach that psychotherapy with borderline patients should focus on the capacity for mentalization, by which we mean the implicit or explicit perception or interpretation of the actions of others or oneself as intentional, that is, mediated by mental states or mental processes. We believe that an important common factor in the psychotherapeutic approaches is the shared potential to re-create an interactional matrix of attachment in which mentalization develops and sometimes flourishes. The therapist mentalizes the patient in a way that fosters the patient’s mentalizing, which is a key facet of the relationship. We recognize that this is not by any means a novel approach. Concepts such as insight, empathy, the observing ego and even introspection have been around throughout the “psychotherapeutic century” (Allen and Fonagy, 2002). The concept of mentalization, in our view, crystallizes the biological and relational processes

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that underpin the phenomena that these venerable clinical concepts denote. It is important to remind ourselves that mentalization is not the same as introspection. Mentalization can be both implicit and explicit. Implicit mentalization is a non-conscious, unreflective, procedural function. As Simon Baron-Cohen put it, “We mind-read all the time, effortlessly, automatically and mostly unconsciously” (Baron-Cohen, 1995). Explicit mentalization is only likely to happen when we hit an interactive snag (Allen et al., 2003). Explicit mentalization, particularly when it is of a higher order, can be the apparent substance of psychological therapy, for example Person A can reflect upon his awareness of what Person B thinks about Person A’s feelings or thoughts. Elsewhere we have pointed out that such explicit mentalization (metacognition) can only be considered genuine and productive when the link between these cognitions and emotional experience are strong. Elsewhere we have referred to this as mentalized affectivity (Fonagy et al., 2002). In fact the dissociation between implicit and explicit mentalization in the course of development may be a defining criterion of psychological disturbance. So what are the strong arguments in favor of mentalization as a key aspect of an effective psychotherapeutic process? First, the foundation of any therapeutic work must, by definition, be implicit mentalization. Without social engagement there can be no psychological therapy, and without mentalization there can be no social engagement. Second, since the work of John Bowlby (1988), it has generally been agreed that psychotherapy invariably activates the attachment system and as a component generates a secure base experience. In our view this is important because the attachment context of psychotherapy is essential for establishing the virtuous cycle of synergy between the recovery of mentalization and a secure base experience. The experience of being understood generates an experience of security which in turn facilitates “mental exploration,” the exploration of the mind of the other to find oneself therein. Third, all therapists, but particularly those of patients whose experience of their mental world is diffused and confusing, will continually construct and reconstruct in their own mind an image of the patient’s mind. They label feelings, they explain cognitions, they spell out implicit beliefs. Importantly they engage in this mirroring process, highlighting the marked character of their verbal or non-verbal mirroring display. Their training and experience further hone their capacity to show that their reaction is related to the patient’s state of mind rather than their own. It is this often rapid non-conscious implicit process that enables the patient with BPD to apprehend what he or she feels. Fourth, mentalizing in psychological therapies is prototypically a process of shared, joint attention, where it is the mental state of the patient where the interests of patient and therapist intersect. The shared attentional processes entailed by all psychological therapies in our view serve to strengthen the interpersonal integrative function (Fonagy et al., 2003). It is not simply what is focused on that we consider therapeutic from this point

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of view, but the fact that patient and therapist can jointly focus on a shared content of subjectivity. Fifth, the explicit content of the therapist’s intervention will be mentalistic regardless of orientation, whether the therapist is principally concerned with transference reactions, automatic negative thoughts, reciprocal roles or linear thinking. These approaches all entail explicit mentalization in so far as they succeed in enhancing coherent representations of desires and beliefs. That this is the case is supported by the common experience that such efforts at explicit mentalization will not only be successful unless if the therapist succeeds in drawing the patient in as an active collaborator in any explication. One may view psychotherapy for borderline individuals as an integrative process where implicit and explicit mentalization are brought together in an act of “representational redescription,” the term Annette Karmiloff-Smith (1992) used to refer to the process by which “implicit information in the mind subsequently becomes explicit knowledge to the mind” (p. 18). Sixth, the dyadic nature of therapy inherently fosters the patient’s capacity to generate multiple perspectives. For example, the interpretation of the transference may be seen as presenting an alternative perspective on the patient’s subjective experience. We view this as optimally freeing the patient from being restricted to the reality of “one view,” experiencing the internal world in a mode of psychic equivalence. This process also becomes accessible through engagement in group psychotherapy. In either setting, mental states are perforce represented at the secondary level and are therefore more likely to be recognized as such as mental representations. It should be remembered that this will only be helpful if implicit and explicit mentalization have not been dissociated and feelings are genuinely felt rather than just talked about. In sum, it is our belief that the relatively safe (secure base) attachment relationship with the therapist provides a relational context in which it is safe to explore the mind of the other in order to find one’s own mind within it. While it is quite likely that this is an adaptation of a mechanism provided to us, probably by evolution to “recalibrate” our experience of our own subjectivity through social interaction, it is a unique experience for individuals with BPD, because their pathology serves to distort the subjective experience of the other to a point where they have little hope of finding their constitutional self therein. The maladaptive interpersonal processes, whether we label these projective identification or pathological reciprocal roles, in most ordinary social contexts only enable these patients to find in their social partner those parts of themselves that they desperately needed to discard in the first place; be they terror, contempt, excitement or pain. The engagement in a psychotherapeutic context, either individually or in groups, thus does far more than provide nurturance, warmth or acceptance. The therapist, in holding on to their view of the patient, and overcoming the patient’s need to externalize and distort the therapist’s subjectivity, simultaneously fosters mentalizing and a secure attachment

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experience. Feeling recognized creates a secure base feeling which in turn promotes the patient’s freedom to explore herself or himself in the mind of the therapist. An increased sense of security in the attachment relationship with the therapist as well as other attachment relationships, possibly fostered by the therapeutic process, reinforces a secure internal working model and through this, as Bowlby pointed out, a coherent sense of the self. Simultaneously the patient is increasingly able to allocate mental space to the process of scrutinizing the feelings and thoughts of others, perhaps bringing about improvements in the fundamental competence of the patient’s mind to interpret functions, which in turn may generate a far more benign interpersonal environment. A limitation of therapy lies in the therapist’s capacity to mentalize, constricted by his or her own attachment history, current interpersonal circumstances, and constitutional capacities. Glen Gabbard (2003) has helpfully drawn our attention to the threat that borderline patients represent to the therapist’s mentalizing capacities. Conclusions Placing mentalization as central to therapy with borderline patients may unify numerous effective approaches to the treatment of this challenging group of patients. While providing a common understanding of why a range of disparate approaches all “work,” the implication of this formulation is not that all approaches are equally effective and the best approach is a judicious combination of existing techniques. It should be clear from the above that therapists will need (1) to identify and work with the patient’s limited capacities; (2) to represent internal states in themselves and in their patient; (3) to focus on these internal states; and (4) to sustain this in the face of constant challenges by the patient over a significant period of time. In order to achieve this level of focus, mentalizing techniques will need to be (1) offered in the context of an attachment relationship; (2) consistently applied over time; and (3) used to reinforce the therapist’s capacity to retain mental closeness with the patient. The manner in which we have organized treatment within a day hospital setting ensures a felicitous context for therapists and patients to focus their work in these ways and to concentrate on mentalization techniques, but we make no claim that our organizing principles are necessarily the best way to arrange treatment. Nevertheless we firmly believe that the following principles are pre-requisites for successful treatment of borderline personality disorder: (1) developing a mentalizing milieu within a day hospital or other context by focusing therapists on their own minds and those of the patient; (2) combining techniques enhancing implicit mentalization with those likely to encourage explicit mentalization; and (3) linking the program so that the different aspects form a coherent whole rather than independent aspects of care.

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R E F EREN CES Allen, J. and Fonagy, P. (2002). The development of mentalizing and its role in psychopathology and psychotherapy. (Technical Report No 02-0048). The Menninger Clinic, Research Department, Topeka, KS. Allen, J., Bleiberg, E. and Haslam-Hopwood, T. (2003). Mentalizing as a compass for treatment. Bull Menninger Clin 1–11, available online at http://www.menningerclinic.com/resources/ Mentalizing-compass.htm. Baron-Cohen, S. (1995). Mindblindness: An Essay on Autism and Theory of Mind. Cambridge, MA: Bradford, MIT Press. Bateman, A. and Fonagy, P. (1999). The effectiveness of partial hospitalization in the treatment of borderline personality disorder – a randomised controlled trial. Am J Psychiatry 156: 1563– 1569. Bateman, A. and Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment of personality disorder. Br J Psychiatry 177: 138–143. Bateman, A. and Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalisation: an 18-month follow-up. Am J Psychiatry 158: 36–42. Bateman, A. and Fonagy, P (2003). Health service utilisation costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalisation versus general psychiatric care. Am J Psychiatry 160: 169–171. Bateman, A. and Fonagy, P. (2004a). Mentalisation based treatment of borderline personality disorder. J Pers Disord 18: 35–50. Bateman, A. and Fonagy, P. (2004b). Psychotherapy for Borderline Personality Disorder: Mentalisation Based Treatment. Oxford: Oxford University Press. Blackburn, R., Crellin, M., Morgan, E. et al. (1990). Prevalence of personality disorders in a special hospital population. J Forensic Psychiatry 1: 43–52. Bowlby, J. (1988). A Secure Base: Clinical Applications of Attachment Theory. London: Routledge. Chiesa, M. and Fonagy, P. (2000). The Cassel personality disorder study: methodology and treatment effects. Br J Psychiatry 176: 485–491. Chiesa, M. and Fonagy, P. (2003). Psychosocial treatment for severe personality disorder: 36month follow-up. Br J Psychiatry 183: 356–362. Chiesa, M., Bateman, A., Wilberg, T. et al. (2002a). Patients’ characteristics, outcome and costbenefit of hospital-based treatment for patients with personality disorder: a comparison of three different programmes. Psychol Psychother Theory Res Practice 75: 381–392. Chiesa, M., Fonagy, P., Holmes, J. et al. (2002b). Health Service use costs by personality disorder following specialist and non-specialist treatment: a comparative study. J Pers Disord 16: 160– 173. Chiesa, M., Fonagy, P., Holmes, J. et al. (2004). Residential versus community treatment of personality disorders: a comparative study of three treatment programmes. Am J Psychiatry 161: 1463–1470. Davidson, K. (2000). Cognitive Therapy for Personality Disorders. A Guide for Clinicians. Oxford: Butterworth Heinemann.

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Borderline personality, day hospitals, and mentalization Dazord, A., Gerin, P. and Seulin, C. (1997). Day treatment evaluation: therapeutic outcome after a treatment in a psychiatric day treatment centre: another look at the equivalence paradox. Psychother Res 7: 57–69. Dick, B. M. and Woof, K. (1986). An evaluation of a time-limited programme of dynamic group psychotherapy. Br J Psychiatry 148: 159–164. DoH (2003). Personality Disorder: No Longer a Diagnosis of Exclusion. London: Department of Health Publications. Dolan, B. M. and Coid, J. (1993). Psychopathic and Antisocial Personality Disorders: Treatment and Research Issues. London: Gaskell. Fonagy, P., Gergely, G., Jurist, E. L. and Target, M. (2002). Affect Regulation, Mentalisation and the Development of the Self. New York: The Other Press. Fonagy, P., Target, M., Gergely, G. et al. (2003). The developmental roots of Borderline Personality Disorder in early attachment relationships: a theory and some evidence. Psychoanal Inquiry 23: 412–458. Fonagy, P., Target, M., Gergely, G., Allen, J. and Bateman, A. (2003). The developmental roots of Borderline Personality Disorder in early attachment relationships: a theory and some evidence. Psychoanal Inquiry 23: 412–458. Gabbard, G. (2003). Miscarriages of psychoanalytic treatment with suicidal patients. Int J Psychoanal 84: 249–261. Grilo, C. M., McGlashan, T. H., Morey, L. C. et al. (2001). Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders. Acta Psychiatr Scand 104: 264–272. Gunderson, J. G. (2001). Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Press. Karmiloff-Smith, A. (1992). Beyond Modularity: A Developmental Perspective on Cognitive Science. Cambridge, MA: MIT Press. Karterud, S., Vaglum, S., Friis, S. et al. (1992). Day hospital therapeutic community treatment for patients with personality disorder: an empirical evaluation of the containment function. J Nervous Mental Dis 180: 238–243. Karterud, S., Pedersen, G., Bjordal, E. et al. (2003). Day treatment of patients with personality disorders: experiences from a Norwegian treatment research network. J Pers Disord 17: 243– 262. Linehan, M. M. (1993). Cognitive-Behavioural Treatment of Borderline Personality Disorder. New York: Guilford. Paris, J. and Zweig-Frank, H. (2001). A 27-year follow-up of patients with borderline personality disorder. Comp Psychiatry 42: 482–487. Piper, W. E., Joyce, A. S., McCallum, M. et al. (1993). Concentration and correspondence of transference interpretation in short-term psychotherapy. J Consult Clin Psychology 61: 586–610. Piper, W. E., Rosie, J., Joyce, A. S. et al. (1996). Time-Limited Treatment for Personality Disorders: Integration of Research and Practice in a Group Programme. Washington, DC: American Psychological Association. Ruiter, C. and Greeven, P. (2000). Personality disorders in a Dutch forensic psychiatric sample: convergence of interview and self-report measures. J Pers Disord 14: 162–170.

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Anthony W. Bateman and Peter Fonagy Ryle, A. (1997). Cognitive Analytic Therapy and Borderline Personality Disorder: The Model and the Method. Chichester, UK: John Wiley & Sons. Simpson, E., Pistorello, J., Begin, A. et al. (1998). Focus on women: use of dialectical behaviour therapy in a partial hospital program for women with borderline personality disorder. Psychiatr Serv 49: 669–673. Swartz, M., Blazer, D., George, L. et al. (1990). Estimating the prevalence of borderline personality disorder in the community. J Pers Disord 4: 257–272. Torgersen, S., Kringlen, E. and Cramer, V. (2001). The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 58: 590–596. Tyrer, P. (2002). Practice guideline for the treatment of borderline personality disorder: a bridge too far. J Pers Disord 16: 113–118. Tyrer, P. and Stein, G. (1993). Personality Disorder Reviewed. London: Gaskell, Royal College of Psychiatrists. Tyrer, P., Remington, M. and Alexander, J. (1987). The outcome of hevrotic disorders after outpatient and day hospital care. Br J Psychiatry 151: 57–62. Vaglum, P., Friis, S., Irion, T. et al. (1990). Treatment response of severe and nonsevere personality disorders in a therapeutic community day unit. J Pers Disord 4: 161–172. Wilberg, T., Friis, S., Karterud, S. et al. (1998a). Outpatient group psychotherapy: a valuable continuation treatment for patients with borderline personality disorder treated in a day hospital? A 3-year follow-up study. Nordic J Psychiatry 52: 213–222. Wilberg, T., Karterud, S., Urnes, O. et al. (1998b). Outcomes of poorly functioning patients with personality disorders in a day treatment programme. Psychiatr Serv 49: 1462–1467. Wilberg, T., Urnes, O., Friis, S. et al. (1999). One-year follow-up of day treatment for poorly functioning patients with personality disorders. Psychiatr Serv 50: 1326–1330. Young, J. E. (1990). Cognitive Therapy for Personality Disorders: A Schema-Focused Approach. Sarasota, FL: Professional Resource Exchange. Zanarini, M. C., Frankenburg, F. R., Hennen, J. et al. (2004). Mental Health Service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. J Clin Psychiatry 65: 28–36.

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Pharmacotherapy of severe personality disorders: a critical review Thomas Rinne and Theo Ingenhoven

Since the late 1970s, there has been remarkable growing optimism about the efficacy of drug therapy in the treatment of patients with personality disorders. But is this optimism justified? Once in a while pharmacotherapists meet personalitydisordered patients who respond dramatically to a new drug after years of struggling in therapy without progress. Open-label, uncontrolled studies are fuelled by these spectacular cures. Scientific journals accept these case histories and open studies as preliminary evidence of the efficacy of a given agent and the effects that might be expected from pharmacological interventions. Subsequent reviews on the efficacy of pharmacological treatment then provide misleading overviews by suggesting that, even in the absence of placebo-controlled randomized clinical trials, these “best” results can shape an evidence-based approach. In spite of the poor evidence for the efficacy of most drugs, official “Guidelines” mimic these reviews and their conclusions and recommendations. For example, the recommendations of the American Psychiatric Association’s practical guideline for the treatment of patients with borderline personality disorder (American Psychiatric Association, 2001) seem to encourage pharmacotherapy to treat symptoms during acute decompensations as well as trait vulnerability. In clinical practice, these recommendations may lead to polypharmacy that is justified by all kinds of speculative assumptions about disbalances of neurotransmitter systems (American Psychiatric Association, 2001). Unfortunately this can lead to iatrogenic neurobiological dysregulations, behavioral dyscontrol, immense side-effects, new disappointments for all parties concerned (therapists, patients, and their families) and low cost-effectiveness. Fortunately, a growing number of well-established placebo-controlled randomized clinical trials are revealing beneficial effects for some drugs targeting specific symptoms in some personality-disordered patients. Although randomized doubleblind placebo-controlled trials are essential to demonstrate efficacy, many trials  C Cambridge University Press 2007

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have serious methodological limitations. Outcome is contradictory and replications are either lacking or have failed. Nevertheless, these results make it possible to develop more realistic pharmacotherapeutic recommendations for clinicians in everyday practice. In this chapter, we briefly discuss the conceptual models and methodological flaws that accompany the empirical research on the efficacy of psychopharmacological interventions for personality disorders. We summarize the treatment algorithms constructed by Soloff (1998, 2000), which were recently adopted in the leading guideline for the treatment of patients with borderline personality disorder (American Psychiatric Association, 2001). Next we critically review the double-blind placebo-controlled randomized clinical trials (RCTs), published in peer-reviewed journals, that focus on treating core personality disorder symptoms (not primary on comorbid Axis I disorders). Finally, we present our own recommendations for pharmacotherapeutic interventions in patients with personality disorders based on this limited evidence. Conceptual issues There are four conceptual models for using medication: (1) treat the disorder itself; (2) treat symptoms or symptom clusters; (3) treat associated Axis I disorders; (4) treat trait vulnerabilities. These models are often complementary rather than mutually exclusive. Treating the disorder itself

Treating the disorder starts from the phenomenological categorical approach in which a personality disorder is postulated as a discrete entity with a specific psychopathology that can be targeted with medication (Gitlin, 1993). For example, schizotypal personality disorder could be considered as a schizophrenia spectrum disorder, so neuroleptics might be helpful in more or less the same way as they are for schizophrenia (Trestman et al., 1995). The characteristic mood swings of borderline personality disorder might, more speculatively, be conceptualized as an atypical rapid-cycling bipolar disorder or cyclothymia, and, as a consequence, mood stabilizers are considered to be the prime therapeutic agents (Akiskal, 1994; Akiskal et al., 2003). In this model, the diagnosis is no longer applicable when the treatment has successfully achieved remission and general adjustment is increased. Treating symptoms or symptom clusters

The symptomatic approach is also based on a phenomenological model. Specific symptoms or symptom clusters assumed to reflect basic biological abnormalities are targeted. The goal is symptomatic improvement rather than changes to the core features of the disorder itself (Soloff, 1998). Relevant symptom clusters within or

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across disorders can be constructed by identifying target symptoms; for example, impulsive-aggression or affective instability. With this approach schizotypal features such as cognitive perceptual symptoms that mimic the positive symptom cluster of schizophrenia would be treated with antipsychotic medication. Treating associated Axis I disorders

The comorbidity model postulates that the positive effects of pharmacotherapy in personality disorder patients are not due to an amelioration of the personality disorder itself but are derived from diagnosable and treatable comorbid Axis I disorders, which can be camouflaged by more prominent features based on the personality pathology. Within this model, an antipsychotic is thought to treat comorbid psychotic disorder and a selective serotonin reuptake inhibitor (SSRI) is prescribed to improve a comorbid major depressive episode, bulimia, social phobia or obsessivecompulsive disorder, but not to directly influence the underlying personality disorder. This model also suggests that the treatment of an Axis I disorder is variably effective in the presence of significant personality disorders. For instance, in borderline patients an atypical depression can be better treated by a monoamine oxidase (MAO) inhibitor than a tricyclic antidepressant (Parsons et al., 1989). Treating trait vulnerabilities

The trait vulnerability model suggests that the pharmacological treatment of personality disorders can best focus on identified core trait vulnerabilities reflecting basic biological neurotransmitter abnormalities (Cloninger, 1987; Cloninger et al., 1993; Gitlin, 1993). Modification of the expression of these trait vulnerabilities is expected to give rise to less symptomatic and less maladaptive behavior. In the literature, we did find a clear example of a study using drugs to directly modify traits in normal volunteers (Knutson et al., 1998), but no examples of research targeting patients with personality disorders. A better example is the Coccaro and Kavoussi (1997) study, in which the efficacy of fluoxetine on trait impulsive aggressiveness was tested in a mixed personality sample. It should be noted that all these concepts are on a theoretical level of development and still lack scientific validation. However, the model has heuristic value and provides the rationale for most pharmacological studies of severe personality disorder. It also formed the starting point for the treatment algorithm developed by Soloff (1998, 2000). The pharmacological treatment algorithms of Soloff and APA borderline guidelines Since the 1980s, there has been growing recognition that severe personality disorders can be described as syndromes of interacting traits, each of which has its origins in psychosocial development and/or biological vulnerability (Siever and

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Davis, 1991), and that some personality dimensions are mediated by dysregulation of neurotransmitter systems. Soloff’s (1998, 2000) algorithms are based on the presumption that pharmacotherapy may be used to threat both symptoms during episodes of (acute) decompensation and the trait vulnerabilities that represent the underlying biological diathesis. By targeting the neurotransmitter physiology that regulates cognition, perception, affect, and impulse, pharmacotherapy may modify the expression of traits allowing for significant relearning of interpersonal behavior. In Soloff’s view, pharmacotherapy is not the treatment of first choice for chronic dysfunctional attitudes about the self or others, and at best can be viewed as an adjunctive treatment aimed at stabilization of symptoms or behavior thereby facilitating psychotherapy. Using a dimensional perspective and a psychobiological model of personality dimensions, pharmacotherapy of the personality-disordered (PD) patient may be reframed as symptom-specific treatment. Treatment algorithms can be derived from research and case experience to assist the clinician in selecting medications for the principal target dimensions in the PD patient: cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. These neurobiological dimensions transcend our definitions of Axis I and II disorders as defined in the DSM (Soloff, 1998). This model and Soloff ’s treatment recommendations were adopted with only minor adjustments by the practical guideline for the treatment of patients with borderline personality disorders (American Psychiatric Association, 2001). According to Soloff, these recommendations can be applied to other personality disorders as well (Soloff, 1998, 2000). 1. Treatment of affective dysregulation symptoms (mood lability, rejection sensitivity, inappropriate intense anger, depressive “mood crashes”, outburst of temper). According to the APA guideline, treatment of first choice for these symptoms is a SSRI or related (not a tricyclic) antidepressant. In the case of anxiety, addition of a benzodiazepine should be considered despite its potential risk. For patients with severe behavioral dyscontrol, a low-dose neuroleptic can be added to the SSRI. Although empirical support for the efficacy of MAO inhibitors exists, they are not considered a first-line treatment because of dietary restrictions and potentially serious side-effects. Mood stabilizers (lithium, valproate, carbamazepine) are recommended as another second-line or adjunctive treatment. 2. Treatment of impulsive-behavioral dyscontrol symptoms (impulsive aggression, self-mutilation, promiscuous sex, substance abuse, reckless spending). Here also SSRIs are the initial treatment of choice. However, when symptoms do not improve, addition of a low-dose neuroleptic may be necessary. Partial efficacy of the SSRI may be enhanced by adding lithium. If the SSRIs are not effective, switching to a MAO inhibitor, or the use of valproate, carbamazepine, or an atypical neuroleptic may be considered.

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3. Treatment of cognitive perceptual symptoms (suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, hallucinationlike symptoms). Low-dose neuroleptics are the treatment of choice and can improve depressed mood, impulsivity, anger, and hostility as well. If the response is suboptimal, the dose should be increased. Atypical antipsychotics are the third choice. Methodological problems As mentioned above, many pharmacological studies on personality disorders suffer from serious methodological flaws. Trials on efficacy should be randomized, double-blind and placebo-controlled with a sufficiently large number of subjects treated for a sufficiently long period of time. In practice, many trials are based on few subjects, making them prone to a type II error due to a lack of power. Furthermore, the comparability of different studies is low because of different inclusion and exclusion criteria and outcome measures. Many pharmacological studies are also based on samples of exclusively one gender, which raises doubts about generalizability to the other gender. In studies with both genders, it is important that both genders are equally represented and the results are corrected for gender-specific effects. Besides sample problems, comparison across studies is also hindered by constant shifting of nomenclature and classification, and the use of different assessment instruments. DSM criteria are operationalized differently across the various semistructural interviews. There are also differences in sensitivity and specificity across instruments with respect to the personality disorders themselves and related Axis I disorders. Another prominent problem is the use of many different outcome measures derived from innumerable self-rating scales and semi-structured interviews. Many of these instruments were developed and validated for Axis I disorders rather than personality disorder, inducing a bias towards Axis I symptomatology. Most standard scales tend to measure characteristics over days or weeks and miss changes in critical features particular to borderline personality disorders such as emotional lability and brief psychotic episodes. In addition, different outcome instruments have been used and only the positive findings reported, without any correction for multiple testing. High comorbidity between personality disorders makes it difficult to delineate patients with “pure” single personality disorders for medication trials. Therefore, most trials do not target personality disorders as categorical entities but address personality disorder symptom clusters such as impulsiveness, affective instability or psychotic-like symptoms. However, within one diagnostic category, we find marked heterogeneity of affective, impulsive, and quasi-psychotic symptoms and behavioral patterns. Moreover, symptoms vary over time within the same patient. For these

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reasons, the results of short-term studies have to be interpreted carefully because symptom reduction can also be due to the self-limiting nature of symptoms. In addition, personality disorder symptoms and behaviors respond to a broad range of interventions and circumstances so that hospitalization or participation in a clinical trial can lead to a marked reduction in symptomatology, especially in borderline patients. This makes ascertainment of the therapeutic benefits of any therapeutic modality difficult. In addition to comorbidity across the personality disorders, there is also high comorbidity between personality disorder and Axis I disorders, e.g., borderline personality disorder and major depression, post-traumatic stress disorder (PTSD), bulimia, drug abuse, and so on. The exclusion of these comorbid factors in a trial reduces the sample to one with mild pathology that is atypical. It would therefore be preferable not to exclude comorbid disorders but to take them into account as covariates in sufficiently large studies to tease apart the pharmacological effects on core personality disorder symptoms from effects on Axis I symptoms. A final problem with studies of personality is the frequent loss of subjects during randomized clinical trials, which influences the apparent efficacy of medication. If only subjects who complete the trial are taken into account, the results are more favorable than they would have been if all eligible subjects had been included. For this reason, completer analyses need to be supplemented with intention-to-treat analyses. Obviously, an intention-to-treatment analysis yields a rather conservative estimate of the true efficacy of the treatment, whereas the completer analysis is biased toward the positive. These observations suggest that a satisfactory evaluation of medication should have the following characteristics: (1) randomized double-blind conditions and placebo control, (2) sufficiently large numbers of participants, (3) clear-cut inclusion and exclusion criteria and description of the investigated sample, (4) inclusion of both genders in equal numbers and correction of gender-specific effects, (5) control for comorbidity and aspecific factors, (6) minimal treatment period of 12 weeks, (7) use of outcome instruments validated for personality disorder pathology, (8) intention-to-treat analysis. Many pharmacological studies in personality disorders do not fulfill these criteria. In this chapter, we discuss only studies which fulfill at least criterion one.

Studies on the efficacy of drugs in personality-disordered patients Antipsychotics Classical antipsychotics

During the 1980s, the effects of neuroleptics on personality disorders were predominantly tested in randomized-controlled trials (RCTs) with borderline and/or

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schizotypal personality disorders. For example, Montgomery and Montgomery (1982) performed a longitudinal RCT of 6 months in a mixed sample of PD patients (predominantly borderline personality disorder, BPD) to test the effects of flupentixol depot 20 mg/4 weeks (n = 14) versus placebo depot (n = 16) on suicidal behavior. The patients were followed for 6 months after admission to a general hospital because of a suicide attempt. Flupentixol depot reduced suicide attempts significantly compared to placebo. Goldberg and colleagues (1986) performed a 12-week RCT with thiothixene (2–35 mg/day; mean 9 mg/day) in a sample of outpatient volunteers (n = 50) with BPD and/or schizotypal personality disorder, who suffered from at least one psychotic symptom. Thiothixene was significantly superior to the placebo with respect to illusions, ideas of reference, psychosis, phobic anxiety, and compulsive symptoms but not depressive symptoms. It is important to note that in this study all outcome measures assess Axis I psychopathology and not personality disorder per se. In a RCT of 5 weeks Soloff et al. (1986b) compared the effects of the tricyclic antidepressant amitriptyline (mean 148 mg/day) with haloperidol (mean 7 mg/day) in a sample of inpatients and outpatients (n = 64) with BPD and/or schizotypal personality disorder with respect to affective and schizotypal symptoms. A significant improvement in favor of haloperidol was obtained in a broad range of symptom patterns such as anxiety, paranoid ideations, and psychoticism. Haloperidol appeared even more effective than amitriptyline with respect to depressive symptoms. The authors extended this study to 90 hospitalized BPD patients (Soloff et al., 1989). A strong placebo improvement was established in all conditions. However, in contrast to amitriptyline, haloperidol appeared significantly superior to placebo with respect to cognitive and affective symptoms. It was also as effective as amitriptyline in treating depression in BPD. Anxiety and hostility improved with both amitriptyline and haloperidol compared to placebo. Soloff et al. (1993) performed a 5-week RCT of haloperidol (4 mg/day), the MAO inhibitor phenelzine (60 mg/day) and placebo in an inpatient sample of BPD patients (n = 108) (Soloff et al., 1993). The intention was to compare the efficacies of neuroleptics and antidepressants on affective, cognitive, and impulsive-aggressive symptoms. In contrast to previous findings, no consistent effects of haloperidol were detected on any symptom cluster. The authors attributed the failure to replicate their previous findings to the less severe pathology in the sample. Of these 108 patients, 54 participated in an outpatient follow-up study lasting 16 weeks. Haloperidol was prescribed up to a maximum of 6 mg/day. Again, haloperidol failed to produce significant effects. Moreover, 64% of the haloperidol group discontinued the medication during follow-up (Cornelius et al., 1993a, 1993b). Cowdry and Gardner (1988) studied the effects of trifluoperazine compared to carbamazepine, alprazolam, and tranylcypromine in a placebo-controlled doubleblind crossover study design in a very small outpatient BPD sample with evident

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behavioral dyscontrol (self-harm and overdosing) and depressive reactions to rejection. The treatment duration of each trial was 6 weeks with a washout period of 2 weeks in between. Trifluoperazine exhibited only a moderate and significantly smaller effect on the behavioral dyscontrol compared to carbamazepine and tranylcypromine. The authors report an improvement of global functioning, anxiety, and depressive symptoms. However, this study is compromised by the small sample and high dropout rate. In conclusion, taken together, the results of these studies with classical antipsychotic medication suggest that there is some empirical evidence that neuroleptics are more effective in improving schizotypal personality disorders and transient psychotic symptomatology rather than BPD symptomatology per se. The cited RCTs do not provide solid evidence for the efficacy of classical neuroleptics in improving typical BPD symptoms such as anxiety, impulsivity, aggression, and suicidal behavior in the long term. Classical antipsychotics might be beneficial for borderline patients during acute states with psychotic-like symptoms. However, these benefits are only short lived and the medication should be administered in low doses because side-effects are common. Moreover, use of these drugs has to be weighted against serious potential side-effects such as movement disorders, mental and physical blunting mimicking depressive symptoms, obesity and hyperprolactinemia with sexual dysfunction or galactorrhea as a consequence. Atypical antipsychotics

Many case studies and open-label studies with atypical antipsychotics (risperidone, clozapine, olanzapine, quetiapine, ziprasidone) suggest that these drugs might be of value in the treatment of borderline and schizotypal personality disorder. Four placebo-controlled double-blind RCTs have been published since 2001. Koenigsberg et al. (2003) included 25 patients with schizotypal personality disorder with low prevalence of comorbid depression and/or BPD in a RCT lasting 9 weeks, in which a low-dose treatment with risperidone (0.25 up to 2 mg/day) was tested. Patients on active medication showed a moderate but significant reduction on positive, negative, and general symptom subscales of the PANSS (Positive and Negative Syndrome Scale) compared to controls. Moreover, 7 out of 15 patients on risperidone dropped out because of sexual dysfunction, galactorrhoea, drowsiness, tiredness, and feelings of weakness. Zanarini and Frankenburg (2001) reported a RCT with female BPD subjects (n = 28) who were randomly assigned to olanzapine (1.25 mg/day at start, adjusted later by a blind psychiatrist; mean 5.33 mg/day) or placebo in a 2:1 ratio. Treatment lasted 6 months. They reported that olanzapine was very well tolerated and that it significantly improved four core areas of borderline psychopathology, namely affect, cognition, impulsiveness, and interpersonal sensitivity. Bogensch¨utz and

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George (2004) also investigated the efficacy of olanzapine (in a flexible dose design 2.5–20 mg/day) on BPD symptomatology in 40 subjects during a period of 12 weeks in a RCT. They observed a significant improvement in the olanzapine group on the scores of the clinical global impression scale modified for BPD patients. However, in contrast to Zanarini’s study, no significant improvements were detected on Symptom Check-List-90 (SCL-90) subscales. It is important to note that both studies reported significant weight gain in patients on olanzapine. Zanarini et al. (2004) reported preliminary data from a randomized trial of fluoxetine, olanzapine, and a combination of both drugs (there was no placebo group). The effects of these three conditions on mood symptoms and impulsive-aggressive behavior were investigated in non-depressed female patients with BPD (n = 45) for 8 weeks. In a flexible dose design, fluoxetine 10–30 mg/day (mean 15 mg/day) and olanzapine 2.5–7.5 mg/day (mean 3.3 mg) were administered, adjusted by an unblinded psychiatrist according to perceived response and side-effects. Olanzapine monotherapy and the olanzapine–fluoxetine combination (OFC) therapy were significantly superior to fluoxetine monotherapy in effects on affective symptoms and impulsive-aggressive behavior. Moreover, olanzapine was also significantly superior to OFC in treating the depressive symptoms of BPD. However, it is important to note that an unusually low dose of fluoxetine was used which might explain the lack of its efficacy. Weight gain was significantly greater in the olanzapine conditions as compared to fluoxetine treatment. Finally, Soler and colleagues (2005) reported on the effects of olanzapine in 60 outpatients with BPD who were included in a 12-week RCT of olanzapine 5–20 mg/day (mean 8.83 mg/day) during Dialectical Behavior Therapy (Soler et al., 2005). Seventy per cent completed the trial and olanzapine was associated with a significant improvement over placebo in depressive symptoms, anxiety, and impulsive-aggressive behavior, but not in self-injuring behavior or suicide attempts. Again weight gain and increase in cholesterol are reported as significant side-effects. In the most recent placebo-controlled RCT with an atypical antipsychotic Nickel investigated the efficacy of aripiprazole with a mean dosage of 15 mg/day. He reported significant improvements of psychotic symptoms, depressed mood anxiety and hostility (Nickel et al., 2006). In conclusion, only risperidone and olanzapine have been tested in RCTs in PD subjects. There is growing evidence from RCTs with olanzapine in BPD that it ameliorates symptoms of impulsivity and aggressiveness, anxiety and depression. In schizotypal personality disorder the only preliminary study performed with risperidone suggests an improvement of schizophrenia-like symptoms. Nevertheless, most RCTs with atypical neuroleptics suffer from high dropout rates, which were not always addressed in intention-to-treat analyses (see “Methodological problems”).

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Taken together at this point, there is growing evidence to support the treatment of BPD with atypical neuroleptics. Moreover, these drugs necessitate strict attention to the potential induction of serious side-effects; namely, metabolic disturbances such as diabetes mellitus II, which concerns 8% of the patients on olanzapine (Farwell et al., 2004), as well as the severe weight gain caused by olanzapine and the sexual disturbances and galactorrhea caused by risperidone. Antidepressants Classical antidepressants

Tricyclic antidepressants (amitriptyline, desipramine) have been studied in only two RCTs of PD patients without comorbid major depression. Soloff tested the efficacy of amitriptyline, haloperidol and placebo in a sample consisting of initially 64 patients with borderline and schizotypal personality disorder (for detailed description of this study see above, “Classical antipsychotics”) (Soloff et al., 1986b). In this study amitriptyline appeared to be equally efficacious as placebo, whereas haloperidol caused significant improvements in a broad spectrum of symptoms, such as depression, anxiety, hostility, paranoid ideation, and psychoticism. In a separate article Soloff pays attention to the paradoxical effects of amitriptyline on borderline patients (Soloff et al., 1986a). Fifteen non-responders on amitriptyline became progressively worse in terms of global functioning, paranoid ideation, and impulsive dysadaptive behavior. The increase in demanding behavior and assaultive acts as compared to placebo was statistically significant. Compared to the placebo group the amitriptyline group improved more on affective symptomatology. The authors conclude that the overall treatment failure in the above-mentioned study was due to the negative behavioral effect of amitriptyline (Soloff et al., 1986a). Links et al. (1990) investigated, in a RCT with random-order crossover design with intervals of 6 weeks for each condition, the effectiveness of lithium and desipramine. Response on mood symptoms, anger and suicidality was tested. Between each condition a washout period of 2 weeks was applied. Seventeen patients diagnosed as borderline patients participated in the trial. No significant differences were found between desipramine (mean 163 mg/day) and placebo regarding the responses based on depression scales. In contrast to lithium, desipramine was ineffective at decreasing irritability, anger, and suicidal symptoms or even worsened these characteristics of the borderline patient. In conclusion, tricyclic antidepressants have not been shown to be effective in ameliorating personality disorder symptoms per se. They are likely to improve affective symptoms in patients with severe personality disorder at the cost of severe behavioral dyscontrol or impairment of cognitive functioning. Therefore, these drugs are not considered an effective compound in the pharmacological treatment

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of personality disorder symptoms. Moreover, given the existing evidence they even seem to be contraindicated.

MAO inhibitors

Cowdry and Gardner (1988) compared tranylcypromine (40 mg/day) in the previously described double-blind crossover study of 6 weeks with placebo, carbamazepine, trifluoperazine and alprazolam in outpatient BPD patients (for description see “Classical antipsychotics”). Twelve patients entered the tranylcypromine trial. The drug was relatively well tolerated. The beneficial effects of tranylcypromine were apparent in both physician’s and patient’s ratings on the domains of anxiety, rage, and other affective symptomatology, such as an increase in euphoria and an increased capacity for pleasure. Soloff compared haloperidol with phenelzine in the treatment of affective, cognitive, and impulsive behavior in 108 patients with BPD (see also “Classical antipsychotics”) (Soloff et al., 1993). Phenelzine (60 mg/day) was mildly superior, but not statistically significantly so, to placebo and haloperidol with respect to depression, anxiety, anger, and hostility, nor was a superior effect of phenelzine over placebo detected with respect to dysphoria and atypical depression. The authors attribute the study’s failure to find a statistically significant difference between phenelzine and placebo to the possibly too low a dosage of phenelzine and the brief treatment period of 5 weeks. To further investigate this issue, Cornelis and Soloff et al. (1993b) performed a follow-up study of 8 weeks with 54 outpatient borderline patients of the abovementioned trial. The daily dose was increased to 90 mg phenelzine. The dropout rate during the continuation study was immense: 64.3% of the haloperidol group, 27.8% of the placebo group, and 45.5% of the patients on phenelzine terminated treatment prematurely. In the phenelzine group a significant weight gain was observed. Phenelzine demonstrated only modest effects in the additional continuation trial on BPD patients’ depressive symptoms over what had been achieved in the brief treatment period of 5 weeks (see above). In conclusion, tranylcypromine is likely to be effective in treating anxiety, rage, and depressive symptomatology in PD patients. However, a study with such a small number lacks sufficient power to find differences between treatment conditions and is thus precluded from conclusions. Given the weak evidence and the potential risk of a hypertensive crisis in the case of diet violation and the risk of lethality in the case of overdosing, tranylcypromine should be prescribed with the greatest reserve to severe personality disorder patients. Phenelzine appeared not superior to placebo in the treatment of personality disorder symptoms in a sufficiently large trial and a follow-up with sufficiently high daily doses. Therefore, phenelzine is not recommended for the treatment of severe personality disorder patients.

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Modern antidepressants

Montgomery investigated the possibility of pharmacological prevention of suicidal behavior in 38 patients with borderline and histrionic personality disorder (Montgomery and Montgomery, 1982; Montgomery et al., 1983). They were treated for a period of 6 months with the tetracyclic antidepressant mianserin or placebo. Subjects received a dose of 30 mg/day before nightfall. At the end point mianserintreated patients exhibited no significant decrease in suicidal behavior compared to placebo. Also in an extended study with 16 additional patients mianserin remained ineffective (Montgomery et al., 1983). Given the lack of significant improvement mianserin is not considered to be a treatment option for the reduction of suicidal behavior in severe personality disorder patients. Selective serotonin reuptake inhibitors (SSRIs) Several open-label studies of SSRIs for small groups of patients with BPD merely suggest that SSRIs may be an effective pharmacological strategy to decrease symptomatology in BPD. However, given the small number of studies and the lack of methodological rigor, there is no firm evidence to support this suggestion. In particular, the low number of placebo-controlled RCTs is currently still a matter of concern. Salzman et al. (1995) were the first to report results of a RCT in a non-patient sample of people with mild to moderate BPD pathology on global functioning, anger, and depression. In all, 14 females and 8 males were recruited for a 13-week trial of fluoxetine. Fluoxetine was administered in a titration scheme, which went up to a maximum of 60 mg/day. The mean daily dose was 40 mg. In a post hoc analysis with correction for the strong placebo effect, statistically significant differences between treatment conditions were obtained with respect to anger and aggression, which appeared to be independent of depression. These promising results have to be seen as preliminary, because of the methodological weakness of the study. Coccaro performed a RCT of fluoxetine in a mixed sample consisting of various personality disorders, all with impulsive-aggressive behavior and irritability (Coccaro and Kavoussi, 1997). The study enrolled 28 male and 12 female subjects from outpatient clinics and through self-referral. Subjects were randomly assigned to fluoxetine or placebo in a ratio 2:1 for a 12-week trial. After a placebo let-in period of 2 weeks for all participants, the daily dose was titrated up to a maximum of 60 mg. A significant improvement with respect to impulsive-aggressive behavior was seen in favor of fluoxetine. This effect was independent of initial levels of depression, anxiety, and/or alcohol abuse. Sleep disturbance, sexual dysfunction, appetite disturbance, restlessness, and nausea or vomiting were the most prominent side-effects of fluoxetine.

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Simpson et al. (2004) studied the effect of 12 weeks fluoxetine (40 mg/day) in a placebo-controlled RCT in 20 female BPD patients during Dialectical Behavior Therapy. Adding fluoxetine did not show any additional benefit on self-report measures of depression, anxiety, anger expression, dissociation, and global functioning. Rinne et al. (2002) conducted a placebo-controlled RCT with fluvoxamine on 38 female BPD outpatients with moderate to severe pathology. The study was a double-blind controlled trial of 6 weeks, followed by a half-crossover. During the first 6 weeks the dose was kept stable at 150 mg/day, after which a dose adjustment was permitted. The results revealed a very significant improvement with respect to rapid mood shifts, anger, and impulsivity in both groups. However, regarding just the rapid mood shifts, a differential and significantly greater improvement in favor of fluvoxamine over placebo could be detected. These results were stable during the entire study. In this context we also refer to another study in which fluoxetine was used. In a preliminary study, Zanarini et al. (2004) compared fluoxetine (10–30 mg; mean 15 mg) with olanzapine and a combination treatment of both drugs (olanzapine with fluoxetine: mean 12.7mg) with respect to mood symptoms and impulsive-aggressive behavior in 45 female BPD patients (see above, “Classical antipsychotics”). There was no placebo control group (Zanarini et al., 2004). No improvement in the outcome measures of the fluoxetine group was detected, in contrast to significant symptom reduction in the olanzapine and the combination therapy groups. As previously mentioned, it is important to note here that, for severe personality disorder, an unusually low dose of fluoxetine was used, which might explain the lack of efficacy of fluoxetine. In conclusion, the results from RCTs of SSRIs with exclusively female samples and predominantly male samples in impulsive and aggressive personality disorders are inconclusive. SSRI treatment is likely to reduce impulsive-aggressive behavior in men but not in women. Although the study by Coccaro and Kavoussi (1997) was performed using a mixed sample of both genders, the female group constituted only a quarter of the total sample and was outnumbered by the male majority. In sum, there is some evidence from one RCT that the SSRI fluvoxamine might be beneficial for affective instability in female borderline patients. Moreover, there is some evidence that SSRIs are effective in decreasing impulsive-aggressive behavior in male subjects with personality disorder.

Mood stabilizers

The treatability of affective dysregulations and behavioral dyscontrol with mood stabilizers has also been investigated in several studies with predominantly BPD subjects.

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Lithium

The only RCT with lithium to have preliminary results is reported by Links et al. In a RCT with a crossover design, the effectiveness of lithium (mean 986 mg/day) and desipramine (mean 163 mg/day) on mood symptoms, anger, and suicidality was tested (Links et al., 1990) (for detailed description see text referring to desipramine in “Classical antidepressants”). No significant difference regarding improvement in mood symptoms was found between the different conditions. A significant improvement of anger and suicidality in favor of the lithium condition was reported based on only one self-report questionnaire. However, the number of participants in the study was very small. Interestingly, the author did not attempt to replicate the result of this first preliminary study in a later study with lithium with a larger number of participants. A drawback of lithium is that it induces considerable side-effects such as polyuria, weight gain, tremor, physical and mental slowing as well as emotional numbness, which, in turn, seriously diminish compliance with the treatment regime. Moreover, the small therapeutic window increases the risk of intoxications, which, in a worst-case scenario, may lead to chronic renal failure or even death. In conclusion, the findings of benefits from lithium are preliminary: some patients with considerable impulse and aggression dysregulations might benefit from treatment with lithium. However, because of its serious side-effects, lithium should only be prescribed as a last-resort option to patients after they have failed to respond to other recommended drugs (such as the mood stabilizers topiramate or valproate, see below). Carbamazepine

The already mentioned double-blind placebo-controlled crossover trial by Cowdry and Gardner (1988), compared the effects of alprazolam, carbamazepine, trifluoperazine, and tranylcypromine on mood symptoms and behavioral dyscontrol (for description see “Classical antipsychotics”) (Cowdry and Gardner, 1988). Here we discuss the results of carbamazepine. Initially included in the trial were 16 severely ill female outpatients with BPD with suicidal and self-harm behavior, violence, and temper outbursts. On carbamazepine (820 mg/day) six of these patients reported allergic reactions whilst on carbamazepine, such as purge rashes to hives, which necessitated early termination of treatment in three cases. With respect to mood symptoms the ratings of the physicians showed a significantly greater improvement in the carbamazepine condition as compared to placebo. Behavioral dyscontrol appeared to be strongly and statistically significantly improved with respect to frequency and severity. Again this study is hampered by the small number of participants and high dropout rates. Cowdry and Gardner mention that three patients unfortunately developed severe melancholia, which remitted on discontinuation (Cowdry and Gardner, 1988).

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De la Fuente and Lotstra (1994) tried to replicate the results concerning the effects of carbamazepine on mood symptoms and behavioral dyscontrol from Cowdry and Gardner, but failed to find a superior effect of carbamazepine over placebo. In this study, 20 patients with BPD were enrolled in a RCT. Treatment lasted for approximately 31 days. The mean daily dose of carbamazepine was sufficient to reach therapeutical plasma levels of between 6.44 and 7.07 g/ml. All patients in the placebo condition completed the trial, but two patients in the carbamazepine condition had to terminate participation because of a dramatic increase of selfharm behavior. The author could not detect any differential effect of carbamazepine between the placebo and experimental condition on the affective symptoms and behavioral dyscontrol. In conclusion, the results of these two placebo-controlled trials with carbamazepine concerning affective instability and behavioral dyscontrol are limited and inconclusive. This might be due to differences caused by the heterogeneity of the two patient samples. Carbamazepine has important and severe adverse effects such as exacerbation of behavioral dyscontrol, the development of severe depression, and allergic reactions. In addition, carbamazepine interacts with the metabolism of many other drugs by inducing hepatic oxidative enzymes that make oral contraceptives unsafe. Given the very limited beneficial effects demonstrated so far of carbamazepine on BPD symptomatology and the considerable number of disadvantages of this drug, it is quite questionable whether carbamazepine deserves a place in the pharmacotherapy of BPD symptoms. It should be prescribed with great reserve. Divalproex

Hollander et al. (2001) was the first to report preliminary results from a small RCT with divalproex in BPD patients (n = 16). The start dosage of 250 mg divalproex was gradually increased to a dosage sufficient to maintain a serum level of 80 g/ml. The study suffered from a high dropout rate, which accounted for nonsignificant results in the intention-to-treat analysis. However, there was a clear and encouraging trend toward more improvement in the medication condition as compared to placebo, which justified further research. In a large multicenter placebo-controlled RCT of 12 weeks, divalproex treatment for impulsive-aggressive behavior was tested on 246 female and male patients (Hollander et al., 2003). Patients were diagnosed in one of three groups: as cluster B personality disorder (n = 96), intermittent explosive disorder (n = 116), or PTSD (n = 34). All patients suffered from a high degree of aggression. The administrated dose of divalproex sodium varied from 500 to 3000 mg/day with a mean modal daily dosage of 1567 mg. Most common adverse events were: abnormal laboratory values (liver function tests, hyperkalemia, hyperglycemia, and hyperuricemia), depression, nausea, and vomiting. In analysis for all three diagnoses with all subjects no statistical differences in improvement could be detected between the divalproex and

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placebo conditions. However, in a secondary analysis for the separate diagnostic groups a statistically significant difference in improvement on aggression, verbal assault, and assault against others was found but only for patients with cluster B personality disorder: here divalproex did better than placebo. Next, Hollander et al. (2005) investigated the predictability of a positive treatment response in terms of trait impulsiveness and state aggression in a new 12-week RCT of 50 BPD patients. The study involved 27 female and 23 male outpatients (Hollander et al., 2005). Patients in the divalproex group received a mean modal dose of 1325 mg/day (range 500–2250 mg/day). A significant difference in improvement of the trait impulsiveness and state aggression was found between both treatments. In conclusion, divalproex sodium or valproate is one of the best and most soundly investigated drugs for the treatment of impulse and aggression dysregulations in BPD patients. The results of these RCTs reveal an improvement of irritability and impulsive aggression after divalproex (valproate). The findings are coherent and replicated in male as well as female patient samples. In general, valproate appears to be moderately well tolerated. It can elicit nausea, vomiting, and depression. Because of the induction of liver function alteration, hyperkalemia and hyperglycemia, periodic laboratory screening for these adverse side-effects is recommended. Valproate can contribute to the treatment of BPD patients; however, because of the side-effect profile and periodic laboratory control, it should not be recommended as a drug of first choice in the treatment of behavioral dyscontrol. Topiramate

Recently topiramate was also investigated regarding its ability to diminish aggressive behavior in male and female patients who are diagnosed with BPD. In the first RCT, by Nickel et al. (2004), 29 female borderline patients were included and given topiramate (n = 19) or placebo (n = 10) for a treatment period of 8 weeks. Topiramate doses were titrated in the first 6 weeks to a dosage of 250 mg/day, after which the dosage was kept constant. The drug was tolerated well, though some subjects complained of fatigue, dizziness, headache, and paresthesia. Furthermore, a significant weight loss was reported in the topiramate group, with a mean difference in weight loss between placebo and topiramate conditions of 2.3 kg. Topiramate was superior to placebo with respect to state anger, trait anger, outwardly directed anger, and anger control. The second topiramate RCT by Nickel et al. was undertaken exclusively with men (n = 42) (Nickel et al., 2005). In all, 22 subjects were randomized to the topiramate condition and 20 to the placebo condition for a period of 8 weeks. The results were similar to the outcome of the study with female patients. However, the mean difference in weight loss between the topiramate arm and the placebo arm was even larger than in the female group: 5 kg.

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A third placebo-controlled RCT with topiramate (mean dosage 200 mg/day for 10 weeks) was performed in 56 female borderline patients. In this third study of the same group with topiramate, significant effects were reported on outcome measures other than in the previous studies. An ameliorating effect of topiramate on ankiety, hostility, and somatization was not observed, whereas effects on symptoms of depression and cognitive perceptual complaints were (Loewe et al., 2006). In conclusion, topiramate is well tolerated, safe and a proper addition to the drug treatment arsenal for behavioral dyscontrol in BPD in both genders as long as loss of weight is an advantage and not a problem. Lamotrigine

Anger and aggression were the target symptoms in the study of Tritt et al. (2005), investigating lamotrigine (titrated to a dose of 200 mg/day) in an 8-week placebocontrolled RCT of 27 female borderline outpatients. No serious side-effects were observed, nor was there a significant effect on body weight. In comparison with the placebo group, and, according to the intention-to-treat principle, highly significant changes were found with respect to anger in favor of lamotrigine. The study has not yet been replicated so it is premature to draw conclusions on the efficacy of lamotrigine.

Conclusion Methodologically sound studies provide evidence that the mood stabilizers topiramate, valproate and probably lamotrigine are suitable drugs for the treatment of affective symptoms related to anger and for impulsive-aggressive behavioral dyscontrol in patients with BPD. Benzodiazepines

There are no data available from double-blind placebo-controlled trials of benzodiazepines on personality disorder patients with the sole exception the tricyclic benzodiazepine alprazolam (Cowdry and Gardner, 1988) (for detailed description of the crossover study with alprazolam, carbamazepine, trifluoperazine and tranylcypromine see “Classical antipsychotics”). The safety data concerning alprazolam are reported elsewhere (Gardner and Cowdry, 1985): 12 patients entered the alprazolam trial of 6 weeks. The average daily dose of alprazolam was 4.7 mg, which is very high: regular dosages amounting to 3 mg are current standards. Of the 12 patients taking alprazolam, 7 had episodes of serious behavioral dyscontrol during the trial. In four cases the trial had to be terminated because of severe episodes of self-harm. This finding is in line with

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other studies also reporting disinhibitions due to benzodiazepines in general and alprazolam in particular. In conclusion, given the addictive properties and the risk of behavioral dyscontrol at high dosages (note: paradoxical effect), benzodiazepines in general and alprazolam in particular should be prescribed with great reserve to BPD patients. The prescription should be limited in dose and to a brief period of time. Sleep disturbances and anxiety during a phase of acute stress form an indication for benzodiazepine treatment. Remaining groups Opiate antagonists

Consistent with the hypothesis that the endogenous opioid system is involved in repetitive self-injurious behavior, accompanied by a reduction of analgesia, dysphoria or dissociation, naltrexone was tested in open studies for its ability to decrease this behavioral pattern in borderline patients. As yet there have been no placebocontrolled RCTs, using natrexone to prove the efficacy in reducing self-mutilation. Searching for a treatment approach of dissociative states in BPD patients, Philipsen et al. (2004) performed a small RCT of naloxone, another opioid receptor antagonist. Nine female inpatients and outpatients fulfilling DSM BPD criteria participated in the trial. Naloxone (0.4 mg) was administered intravenously in an acute dissociative state. Dissociative states were assessed before and after a single dose of naloxone or saline placebo. No differential effects in the significant decrease of dissociative symptoms after naloxone or placebo could be demonstrated. In conclusion, on the basis of the data provided naloxone cannot be recommended for the treatment of dissociative states in BPD patients. Omega-3 fatty acid

Zanarini and Frankenberg had the innovative idea, derived from depression research, to investigate the effects of omega-3 fatty acids on mood in BPD patients (Zanarini and Frankenburg, 2003). Decreases in mood symptoms and aggressive behavior in response to ethyl-eicosapentaenoic acid (E-EPA) in 30 female patients fulfilling BPD criteria were evaluated in a RCT of 8 weeks. The participants were distributed in a ratio of 1:2 to the placebo and active condition respectively. In the active condition 500 mg/day acid was administered. The authors describe a significant difference in improvement of mood symptoms and aggressive-impulsive behavior on both outcome measures in favor of E-EPA. In conclusion, the results of this relatively small and short-lasting RCT are quite promising for the treatment of mood symptoms and impulsive-aggressive behavior, also because of a favorable side-effect profile.

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Table 9.1 Pharmacotherapeutic strategies in severe personality disorders

Algorithms: Soloff (1998, 2000) and APA Treatment Guideline BPD (2001) Cognitive perceptual symptoms

Impulsive behavioural dyscontrol

Affective dysregulation

1. Classical antipsychotics, low dosea 2. Classical antipsychotic increase doseb 3. Atypical antipsychotic

Recommendations: Rinne and Ingenhoven (January 2007) Psychotic-like symptoms 1. Classical or atypical antipsychotics, low dosea 2. Increase doseb Dissociation 1. No recommendation (avoid benzodiazepines, tricyclic antidepressants and polypharmacy)

1. 2. 3. 4.

SSRIs 1. Topiramate Add classical antipsychotic 2. SSRI (fluoxetine)(male patients) or Add lithium or switch to MAOI valproate (female and male patient) Carbamazepine, valproate or 3. Add classical or atypical antipsychotic lithium (low dosea ) or switch to lithium 5. Atypical antipsychotic (avoid benzodiazepines, tricyclic antidepressants, and polypharmacy) 1. SSRIs or related antidepressants (2×) 2. Anxiety: add benzodiazepine (clonazepam) Anger: add antipsychotic, low dosea 3. MAOI 4. Lithium, carbamazepine or valproate

Affective lability 1. SSRI (fluvoxamine) 2. Valproate “Depressed mood” (without major depression or affective lability) 1. Atypical antipsychotic (olanzapine) 2. MAOI (tranylcypromine) (avoid tricyclic antidepressants or carbamazepine) Anger, hostility, irritability (without behavioral dyscontrol) 1. Topiramate or valproate 2. Classical or atypical antipsychotic (low dosea ) Anxiety 1. Classical or atypical antipsychotic (low dosea ) 2. No medication?; low-dose benzodiazepine? 3. MAOI (tranylcypromine)

a b

Classical antipsychotics, low dose = equivalent haloperidol 1–4 mg. Classical antipsychotics, increase dose = up to equivalent haloperidol 4–6 mg.

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Discussion Towards a revised approach of pharmacotherapeutic interventions in patients with personality disorders.

Although miraculous responses to almost every medicine have been reported in case histories and open studies, empirical research makes it clear that only placebocontrolled RCTs can give us an answer as to whether specific drugs are effective against the symptoms or maladaptive behaviors described in PD patients. The introduction of symptom clusters and treatment algorithms described by Soloff (1998) and the APA BPD guideline (American Psychiatric Association, 2001) seems to be the most acceptable frame of reference for reviewing the results of the efficacy trials and for formulating treatment guidelines for clinical practice based on principles of evidence-based medicine. The results of recent research on the basis of just RCTs guide the reformulation of Soloff ’s treatment algorithms. In the final part of this chapter we propose an updated, evidence-based revision of the treatment guidelines using the conceptualization as formulated by Soloff of the symptom cluster of personality pathology, which transcends DSM IV categorical personality disorder diagnoses: (1) cognitive perceptual symptoms; (2) impulsive behavioral dyscontrol; (3) affective dysregulation.

Cognitive perceptual symptoms

Within this realm, in contrast to Soloff’s algorithms, we advise differentiating between psychotic-like symptoms and dissociation. There is evidence that dissociative symptoms, such as derealization and depersonalization, do not necessarily co-occur with the other psychotic-like symptoms mentioned, but can be associated with anxiety or post-traumatic stress.

Psychotic-like symptoms

Suspiciousness, referential thinking, paranoid ideation, illusions, hallucinatory-like symptoms and odd or eccentric thinking can be found chronically or intermittently in Cluster A personality disorders, especially schizotypal personality disorder. In Cluster B BPD most of these cognitive perceptual symptoms are described as stressrelated transient phenomena or “micropsychotic episodes.” Generalizing, antipsychotic medication, whether classical or atypical, can effectively reduce these symptoms. They can be used in low dose for a short period of time (weeks) or intermittently during the course of the disorder in both schizotypal and borderline personality disorder with cognitive perceptual symptoms. Because of potential side-effects, chronic use or higher doses are justified only when symptoms persist, especially in schizotypal personality disorder. In BPD (without comorbid psychotic disorder) long-term treatment with antipsychotics lacks any supportive

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evidence and cannot be recommended (long-term use of classical antipsychotics is not well tolerated by BPD patients). It is not clear whether atypical antipsychotics (risperidone, olanzapine) are better than the older classical (cheaper) ones (thiothixene, haloperidol) and which antipsychotics are the most effective and should be first choice within each group of drugs. So the presence or absence of (expected) specific side-effects (such as movement disorders, weight gain, sexual dysfunction) and cost-effectiveness will guide us to the first choice in individual cases. Clozapine is not recommended because of the absence of proven efficacy and the potential severe side-effects (agranulocytosis). When the antipsychotic drug is effective in reducing cognitive perceptual symptoms one can also expect a decrease of symptoms in the realm of impulsive dyscontrol and affective dysregulation, as well as an increase in global functioning. There is no good evidence that antipsychotic medication is effective for borderline patients who lack cognitive perceptual symptoms, with the exception of olanzapine (see below). There is also no evidence that other pharmacotherapeutic drugs are effective in reducing these cognitive perceptual symptoms in personality disorder. In contrast, there is some evidence that tricyclic antidepressants (e.g., amitriptyline) can induce suspiciousness and paranoid ideation in BPD. Dissociation

No evidence is found for the usefulness of antipsychotic drugs in the treatment of dissociative phenomena such as depersonalization and derealization (in the absence of psychotic-like features). Transient dissociative symptoms can be found in BPD but also as a non-prototypical feature in other personality disorders. There is even a risk of an iatrogenic exacerbation of dissociative symptoms by high-dose antipsychotics and polypharmacy, and a risk of paradoxical effects during the use of benzodiazepines (alprazolam) or tricyclic antidepressants (amitriptyline). Opiate antagonists also appeared to be ineffective in a preliminary controlled study. Impulsive-behavioral dyscontrol

This symptom cluster includes a broad spectrum of symptomatic behaviors including suicide attempts, self-mutilation, violent behaviors, binge eating, drug/alcohol abuse, promiscuity, spending, gambling, and temper outbursts. Prototypically these symptoms are found most frequently in Cluster B personality disorders, especially in BPD. The SSRIs are often recommended for the treatment of these impulsive or aggressive-behavioral dyscontrol symtoms. In Soloff’s algorithms and the APA BPD Guideline, SSRIs are the initial treatment of choice. However, the evidence supporting this class of antidepressants is weaker than suggested. There is certain evidence supporting the use of SSRIs in aggressive-impulsive behavior in men. However, in

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women this indication is very controversial. Although one RCT provided some evidence that flupentixol, an antipsychotic drug, can be helpful in preventing suicide attempts, there is no clear evidence that antipsychotics are effective in reducing behavioral dyscontrol in general in the absence of cognitive perceptual symptoms, with the exception of olanzapine. So the second step in Soloff ’s algorithm, to add a neuroleptic in the case of a partial response on a SSRI, is also very controversial. Adding lithium, Soloff ’s third step in the case of a partial response on a SSRI, is no less controversial since only one small preliminary RCT has shown that lithium is effective on anger and suicidal items as assessed as the outcome measure using one questionnaire. Given the severity of side-effects and potential danger, lithium should be prescribed only as a last option in a very well monitored treatment. In contrast, recent RCTs with mood stabilizers made it clear that topiramate and valproate (and perhaps also lamotrigine) can be very effective in improving state and trait anger, anger control and outwardly directed aggression. Topiramate seems to have a favorable side-effect profile compared to valproate. Carbamazepine treatment results are controversial with respect to impulsive-aggressive behavior, moreover severe side-effects such as allergic reactions and the induction of severe depression makes this compound unfavorable for prescription to PD patients. Balancing the evidence of efficacy against the side-effects, we are inclined to recommend a hierarchy in the choice of the drugs tested for the treatment of impulsive-aggressive behavior (in the absence of cognitive perceptual symptoms): 1. Topiramate (and perhaps lamotrigine or omega fatty acids?) 2. Fluoxetine (primarily for male patients) or valproate (both sexes) 3. Addition of antipsychotic (classical or atypical) 4. Addition of lithium (very last choice). Note: alprazolam and amitriptyline are at risk of inducing severe behavioral dyscontrol. Affective dysregulation

The presence of cognitive perceptual symptoms or impulsive dyscontrol warrants interventions described in, respectively, the first and second treatment algorithms mentioned above. Third in this hierarchy is the symptom domain of affective dysregulation in which we find a pallet of target symptoms such as affective lability, depressed mood, anger/hostility (without behavioral dyscontrol), and anxiety. Affective lability, rapid mood shifts, rejection sensitivity and mood crashes are described in personality disorders, especially those in Cluster B. Soloff ’s algorithm advises an SSRI as first choice, adding benzodiazepines or antipsychotics when necessary. Studies using fluoxetine do not confirm this recommendation. There is evidence from one study that an SSRI (fluvoxamine) decreases rapid mood shifts in female BPD patients, and some evidence from another study that valproate

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can stabilize affective lability. There is also some evidence that (in the absence of a comorbid bipolar disorder) antipsychotics, tricyclic antidepressants, MAO inhibitors and some of the other “mood stabilizers” (lithium, carbamazepine) do not decrease these rapid mood swings. In contrast to Soloff ’s algorithms we advise an SSRI (step 1) or valproate (step 2) for affective lability (in the absence of cognitive perceptual symptoms and impulsive behavioral dyscontrol). When mood is recurrently depressed but not shifting all the time, and there is still no comorbid major depressive disorder, pharmacological treatment is again controversial. There is no clear empirical evidence that modern antidepressants such as SSRIs are effective (first step in Soloff ’s algorithm). Tricyclic antidepressants are not recommended, because of the risk of serious behavioral dyscontrol. The mood stabilizers lithium, carbamazepine and valproate turn out to be ineffective in RCTs targeted at depressed mood in PD patients. The efficacy of classical antipsychotics against a depressed mood was evident only in the presence of cognitive perceptual symptoms, not in their absence. Two RCTs using olanzapine indicate a positive effect on mood. Improvement of depressed mood in BPD patients is reported by the MAO inhibitor tranylcypromine in one small study, which provides very limited evidence. Phenelzine turned out to be ineffective. Because of serious potential sideeffects and dietary restrictions, MAO inhibitors are not recommended as a first or second step, and certainly not in parasuicidal patients. Omega fatty acids improved depressed mood in BPD patients in one RCT and have a very favorable side-effect profile. This hopeful outcome needs replication. Results of studies on reducing anger, hostility and irritability (without behavioral dyscontrol) using SSRIs, antipsychotics, lithium or MAO inhibitors are preliminary or controversial. In contrast to the recommendations of these drugs in Soloff ’s algorithms, topiramate and valproate (and probably lamotrigine) were recently found to reduce these symptoms more appropriately and seem to be the drugs of first and second choice since they are tolerated well to moderately well. RCTs in BPD patients provide evidence that symptoms of anxiety are decreased by classical antipsychotics (thiothixene and haloperidol), atypical antipsychotics (olanzapine) and MAO inhibitors (tranylcypromine). Because of their serious potential side-effects and dietary restrictions, MAO inhibitors are not recommended as a first or second step. The efficacy of benzodiazepines at decreasing anxiety in personality disorder has not been confirmed by RCT. In contrast to Soloff ’s algorithm we cannot recommend benzodiazepines as a second step to reduce anxiety because benzodiazepines can induce serious behavioral dyscontrol. A critical review of exclusively double-blind placebo-controlled RCTs in patients with severe personality disorders (not focusing primarily on comorbid Axis I disorders) reveals a pessimistic view concerning the poor evidence on which most treatment recommendations are based. Moreover, all pharmacological research in

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personality disorders is entirely concentrated on BPD patients with the exception of a few trials performed on schizotypal PD patients. An intensive literature search on PubMed did not yield any RCTs of patients suffering from one of the remaining DSM IV personality disorders. Many trials are hampered by major methodological limitations. Despite the lack of soundness, these studies are frequently quoted and used as a standard. This means that many treatment recommendations based on these studies, and in many cases also based on open-label studies, do not exceed the status of a myth. Although we based our chapter on the existing evidence we cannot state that other drugs that were not investigated or were investigated in inadequate doses or using samples that were too small are not effective. Fortunately there is an increasing number of qualitatively sound trials that provide good evidence about the efficacy of certain compounds for the treatment of severe personality disorder features. However, we can state that the field of pharmacological research in personality disorders remains in its infancy. Methodological guidelines, consensus about a restricted number of diagnostic instruments, and outcome instruments validated for personality disorders are necessary conditions to improve the quality and comparability of future pharmacological trials. Last but not least, a more critical attitude of all participants in the field in general is necessary. Authors have to resist the temptation and pressure to publish only positive results, reviewers and editors have to judge submitted data critically, and conform to rigid quality standards, and the writers of reviews have to base their conclusions and treatment recommendations on the critical analysis of original articles only. These strategies will also improve the field of pharmacological treatment of severe personality disorders.

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Pharmacotherapy of severe personality disorders Cloninger, C. R., Svarkic, D. M. and Przybeck, T. R. (1993). A psychobiological model of temperament and character. Arch Gen Psychiatry 50(12): 975–990. Coccaro, E. F. and Kavoussi, R. J. (1997). Fluoxetine and impulsive aggressive behavior in personality-disordered subjects. Arch Gen Psychiatry 54: 1081–1088. Cornelius, J. R., Soloff, P. H., George, A., Ulrich, R. F. and Perel, J. M. (1993a). Haloperidol vs. phenelzine in continuation therapy of borderline disorder. Psychopharmacol Bull 29: 333– 337. Cornelius, J. R., Soloff, P. H., Perel, J. M. and Ulrich, R. F. (1993b). Continuation pharmacotherapy of borderline personality disorder with haloperidol and phenelzine. Am J Psychiatry 150: 1843–1848. Cowdry, R. W. and Gardner, D. L. (1988). Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Arch Gen Psychiatry 45: 111–119. De la Fuente, J. M. and Lotstra, F. (1994). A trial of carbamazepine in borderline personality disorder. Eur Neuropsychopharmacol 4: 479–486. Farwell, W. R., Stump, T. E., Wang, J., Tafesse, E., L’Italien, G. and Tierney, W. M. (2004). Weight gain and new onset diabetes associated with olanzapine and risperidone. J Gen Intern Med 19: 1200–1205. Gardner, D. L. and Cowdry, R. W. (1985). Alprazolam-induced dyscontrol in borderline personality disorder. Am J Psychiatry 142: 98–100. Gitlin, M. J. (1993). Pharmacotherapy of personality disorders: conceptual framework and clinical strategies. J Clin Psychopharmacol 13: 343–353. Goldberg, S. C., Schulz, S. C., Schulz, P. M., Resnick, R. J., Hamer, R. M. and Friedel, R. O. (1986). Borderline and schizotypal personality disorders treated with low-dose thiothixene vs placebo. Arch Gen Psychiatry 43: 680–686. Hollander, E., Allen, A., Lopez, R. P. et. al. (2001). A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 62: 199–203. Hollander, E., Tracy, K. A., Swann, A. C. et al. (2003). Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology 28: 1186–1197. Hollander, E., Swann, A. C., Coccaro, E. F., Jiang, P. and Smith, T. B. (2005). Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder. Am J Psychiatry 162: 621–624. Knutson, B., Wolkowitz, O. M., Cole, S. W. et al. (1998). Selective alteration of personality and social behavior by serotonergic intervention. Am J Psychiatry 155: 373–379. Koenigsberg, H. W., Reynolds, D., Goodman, M. et al. (2003). Risperidone in the treatment of schizotypal personality disorder. J Clin Psychiatry 64: 628–634. Links, S., Steiner, M., Boiago, I. and Irwing, D. (1990). Lithium therapy for borderline patients: preliminary findings. J Pers Disord 4: 173–181. Loewe, T. H., Nickel, M. K., Meuhlbacher, M. et al. (2006). Topiramate treatment for women with borderline personality disorder. J Clin Psychopharmacol 26: 61–66. Montgomery, S. A. and Montgomery, D. (1982). Pharmacological prevention of suicidal behaviour. J Affect Disord 4: 291–298.

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Thomas Rinne and Theo Ingenhoven Montgomery, S. A., Roy, D. and Montgomery, D. B. (1983). The prevention of recurrent suicidal acts. Br J Clin Pharmacol 15(Suppl 2): 183S–188S. Nickel, M. K., Nickel, C., Mitterlehner, F. O. et al. (2004). Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study. J Clin Psychiatry 65: 1515–1519. Nickel, M. K., Nickel, C., Kaplan, P. et al. (2005). Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study. Biol Psychiatry 57: 495–499. Nickel, M. K., Loewe, T. H., Meuhlbacher, M. et al. (2006). Aripiprasole in the treatment of patients with borderline personality disorder; a double-controlled study. Am J Psychiatry 163: 833– 838. Parsons, B., Quitkin, F. M., McGrath, P. J. et al. (1989). Phenelzine, imipramine, and placebo in borderline patients meeting criteria for atypical depression. Psychopharmacol Bull 25: 524–534. Philipsen, A., Schmahl, C. and Lieb, K. (2004). Naloxone in the treatment of acute dissociative states in female patients with borderline personality disorder. Pharmacopsychiatry 37: 196– 199. Rinne, T., van den, B. W., Wouters, L. and van Dyck, R. (2002). SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder. Am J Psychiatry 159: 2048–2054. Salzman, C., Wolfson, A. N., Schatzberg, A. et al. (1995). Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder. J Clin Psychopharmacol 15: 23–29. Siever, L. J. and Davis, K. L. (1991). A psychobiological perspective on the personality disorders. Am J Psychiatry 148: 1647–1658. Simpson, E. B. Yen, S., Costello, E. et al. (2004). Combined dialectical behavior therapy and fluoxetine in the treatment of borderline personality disorder. J Clin Psychiatry 65: 379–385. Soler, J., Pascual, J. C., Campins, M. J. et al. (2005). Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder. Am J Psychiatry 162: 1221–1224. Soloff, P. H. (1998). Symptom-specific treatments for cognitive-perceptual, affective, and impulsive-behavioral dysregulation. Bull Menninger Clin 62: 195–214. Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am 23: 169–92, ix. Soloff, P. H., George, A., Nathan, R. S., Schulz, P. M. and Perel, J. M. (1986a). Paradoxical effects of amitriptyline on borderline patients. Am J Psychiatry 143: 1603–1605. Soloff, P. H., George, A., Nathan, R. S. et al. (1986b). Progress in pharmacotherapy of borderline disorders. A double-blind study of amitriptyline, haloperidol, and placebo. Arch Gen Psychiatry 43: 691–697. Soloff, P. H., George, A., Nathan, S. et al. (1989). Amitriptyline versus haloperidol in borderlines: final outcomes and predictors of response. J Clin Psychopharmacol 9: 238–246. Soloff, P. H., Cornelius, J., George, A., Nathan, S., Perel, J. M. and Ulrich, R. F. (1993). Efficacy of phenelzine and haloperidol in borderline personality disorder. Arch Gen Psychiatry 50: 377–385. Trestman, R. L., Keefe, R. S., Mitropoulou, V. et al. (1995). Cognitive function and biological correlates of cognitive performance in schizotypal personality disorder. Psychiatry Res 59: 127–136.

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Pharmacotherapy of severe personality disorders Tritt, K., Nickel, C., Lahmann, C. et al. (2005). Lamotrigine treatment of aggression in female borderline-patients: a randomized, double blind, placebo-controlled study. J Psychopharmacol 19: 287–291. Zanarini, M. C. and Frankenburg, F. R. (2001). Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo-controlled pilot study. J Clin Psychiatry 62: 849–854. Zanarini, M. C. and Frankenburg, F. R. (2003). Omega-3 fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry 160: 167–169. Zanarini, M. C., Frankenburg, F. R. and Parachini, E. A. (2004). A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry 65: 903–907.

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Severe cases: management of the refractory borderline patient Bert van Luyn

Borderline personality disorder (BPD) is a severe but not hopeless condition. Gradual improvement over time can be expected (Paris, 2003), and active psychotherapeutic treatment may be effective (Bateman and Fonagy, 2004; Giesen-Bloo et al., 2006; Linehan, 1993; Perry et al., 1999). However, not all patients respond well: some do not improve at all while others become very self-destructive, drop out of therapy, or worsen. This chapter will focus on treatment strategies and the management of severe, refractory patients. The refractory borderline patient Every treatment setting has its own difficult, “refractory” borderline patients: they do not respond well to any treatment, have had multiple therapists, multiple suicide attempts, severely harm themselves, and make frequent use of emergency services. Most are unemployed, and have no stable support system or are still dependent on exhausted parents. Some are left without any treatment at all. Several factors contribute to this unfortunate outcome. First, BPD in itself is a severe, to some extent chronic, disorder (Paris, 2003). Though recent longitudinal studies on personality disorders show that borderline patients improve on a psychopathological level, their functional impairment improves much less (Skodol et al., 2005). Moreover, since personality psychopathology usually begins in early adulthood or adolescence, the risks of severe, accumulating derailments in psychosocial functioning are substantial: “The possibility of chronic, residual impairment from which a person never completely recovers is real” (Skodol et al., 2005). Psychopathological improvement is less for what seem core dimensions of BPD: affective instability and anger. Coping behaviors such as selfinjury and “behaviors against abandonment” are more changeable (McGlashan et al., 2005). Comorbidity is high: most BPD patients meet criteria for other  C Cambridge University Press 2007

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personality disorders (Pfohl and Blum, 1991) and more often than not such patients also have symptom disorders. When treated for these Axis I problems, they do less well than patients without personality disorders (Shea et al., 1990). According to Paris (2003) the borderline diagnosis itself is a diagnosis of failure: patients tend to receive it when their treatment has failed. Second, BPD patients readily evoke strong transference reactions. Hinshelwood (1999) notes that professionals working with these patients easily exchange their objective, neutral stance for a moral, denouncing position (“bad,” not “mad”), and in doing so, often repeat the life experiences of these individuals. Betan et al. (2005) found that BPD patients elicit the same countertransference responses in their therapist, regardless of their therapeutic approach. The pattern of countertransference response characteristic of primarily Axis II Cluster B patients was an “overwhelmed, disorganized” response, referring to a desire to avoid or flee the patient, and strong negative feelings, including dread, repulsion, and resentment. Important in these countertransference reactions is the severe suicidality of borderline patients: suicidal acts early in treatment, threats in later phases, and, even with successful treatment, suicidal ideas for a long time. Many therapists do not like to treat patients where fatal mistakes are always in the air: these are the patients that “therapists love to hate” (Paris, 2003). Third, there might be some degree of iatrogenesis with these patients: severe borderline patients are sometimes offered treatment that pushes their limits and makes things worse. Without a doubt, psychotherapies late in the last century that asked for self-directedness, autonomy, and motivation underestimated the enormous deficits of many borderline patients. Behaviors that should have been the goal of treatment were made prerequisites for therapy, and some therapies may have been too confrontational, offering too little support. Often there is undertreatment: even in affluent societies, less equipped staff often deal with more severe patients. “There are many such patients generally treated in low-cost or free clinics by overworked staff members who have little to provide for their patients beyond sympathy and pills” (Stone, 2001). Worse, not being treated at all is by no means an exception for the severe cases. Paris (2003), presenting cases from his 27-year follow-up study, describes how all previous therapists refused to see “Frances,” a “famous” patient with BPD, who had more than 20 admissions, and was well known for her history of harassment and threats against her therapists. In the end she was only monitored by her family doctor. She resembled “Rachel,” an impulsive, multiple substance abuser who at age 35 years commited suicide: “ . . . Rachel reached a point at which no therapist of the hospital was willing to treat her.” Livesley (2003) tells the story of “Kelly,” a 40-year-old hostile, impulsive, suicidal, and in the end lonely woman. He describes the dilemma therapists face very well: “This is a Catch-22 situation, in which a stable treatment context is required to

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disrupt repetitive self-harm, but the frequency of this behavior and the severity of psychopathology prevent the establishment of a stable treatment process.” As in Frances’ case, treatment was eventually terminated. And last, some of these supposedly severe borderline patients may actually not have BPD; assessing these sometimes pan-symptomatic patients may be very difficult, paving the way to misdiagnoses and polypharmacy. These patients may show psychotic-like episodes beyond borderline criteria that resemble schizophrenic states but do not fit DSM categories. Clinicians in these cases often combine different classification models (“a DSM-IV borderline patient with a psychotic structure according to Kernberg”) or suspect mild variations of schizophrenia. Evaluating the status of what patients report about their symptoms may be difficult in these cases: is what they report what they really experience, or do they present their experiences in such a way to elicit certain behaviors in their caregivers, for instance not leaving them. There might even be so little “self,” that a patient hardly knows what he or she really experiences, or as patient X said: “I don’t know what happened yesterday, and if you ask me in a minute what we are discussing now, I won’t know, and if you ask me what I will be doing next . . . I do not know either!” Sometimes countertransference reactions (“if there is a lot of trouble, it must be a borderline patient”) prevent adequate treatment; for instance, when the disruptive, externalizing behavior of a non-disorganized paranoid schizophrenic patient is mistakenly diagnosed as borderline pathology, or when a severe comorbid state such as mania is not treated, because the condition is labelled “borderline acting out.” Characteristics of the refractory borderline patient Course- and long-term outcome studies such as Paris’ 27-year follow-up, Stone’s well-known follow-up study of 500 BPD patients (1990, 1993), and the recent CLPS (Collaborative Longitudinal Personality Disorders Study (Gunderson et al., 2006)) suggest some common features of the refractory group. Gunderson et al. (2006) found that higher levels of BPD criteria and functional disability at baseline level, and childhood trauma predict a poor outcome at a 2-year follow up. Stone (1990) mentions several positive prognostic measures, distinguishing easily treatable patients from those difficult or impossible to treat: friendliness, likeability, intelligence, motivation, psychological-mindedness, moral sense, self-discipline, intro- versus extra-punitive defensive style, and capacity for empathy. In contrast, hostility and inordinate anger predict worse outcomes, especially if they spill over into the therapeutic relationship. Like Paris (2003) and Zanarini et al. (2003), Stone described how the life trajectory of many borderline patients improves throughout the third decade and

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beyond. Those individuals that remained chronically angry, however, did worse in their mid-40s, often because they alienated and exhausted spouses, partners or others that they depended on for support. Needing someone desperately, loneliness became their fate. Paris (see also Chapter 7) showed that suicide completion in BPD patients also occurred later in the course of the illness, generally in patients who did not respond well to a series of treatments. It appears that if BPD patients commit suicide, they do so because they feel life has proven to them that all hope is lost. Chaotic impulsivity is also associated with negative outcome. Impulsivity, especially when combined with hostility, makes long-term relationships almost impossible, and hence deprives the patient of support. Borderline patients with sociopathic features also do badly. As Stone (2001) noted, most are lacking “patienthood,” which makes them unsuitable for therapy. They lack attachment, do not present as suffering from a psychological condition but blame others, without accepting responsibility for their behavior. Linked to impulsivity is substance abuse, another major risk factor that predicts a declining course of illness and suicide. Links et al. (1995) showed that pre-existing substance abuse was an important predictor of poor outcome in patients with BPD, while Zanarini (1993) found that BPD patients with the best outcome were the ones who sustained sobriety over the follow-up period. Environmental factors Some environmental factors correlate with poor outcome, including parental brutality and antisocial traits, and a chaotic impulsive environment. Bateman and Fonagy (2004) refer to severe parental deficiencies in teaching the child to mentalize. Stone (1990) found that female borderline patients who were the victim of incest by a relative of the older generation have a heightened risk for suicide and poor Global Assessment Scores (GAS). Severe incest also correlates with dissociative reactions and quasi psychotic symptoms. In my experience, these symptoms are typical in abused refractory patients. Severe self-harm and extremely dangerous suicidal behavior often occur in dissociative states, sometimes induced by alcohol or drug abuse. Structurally, these patients are on the edge of borderline and psychotic organization (Kernberg, 1984). Most refractory borderline patients have a long psychiatric history, often beginning early in life. An early onset, as Paris (2003) states, increases the probability that an illness becomes chronic and severe. These conditions often have a substantial genetic component. The above findings of long-term outcome studies correspond with what one might expect from a stress-diathesis model (Monroe and Simons, 1991). This model suggests at least two types of refractory patients: those with strong biological dispositions raised by incompetent or averagely competent but exhausted parents, and those with average vulnerability exposed to extreme environmental

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stress such as early severe abuse or neglect. Chaotic-impulsive and inordinately hostile patients probably largely represent the first group. In the second group of early, enduring abuse or neglect, the biological stress response patterns themselves are modified. A problem of all refractory patients is that they lack a capacity for sharing, attachment, and empathy which makes it difficult to establish a therapeutic alliance. No alliance, no therapy Psychotherapy is a collaborative enterprise. All therapies need to develop a working alliance. Gunderson (2001) describes three types of therapeutic alliance. First, a contractual alliance; this type refers to the agreement between patient and therapist on treatment goals, means, roles, and responsibilities. It is the minimal agreement needed before starting therapy. The second, affective, component of the working alliance is crucial: it refers to the patient’s capacity to experience the therapist as “caring, understanding, genuine and likable” (Gunderson, 2001). This part of the alliance determines whether therapy will continue. The third, most mature, form refers to the patient’s reliably collaborating with the therapist to change the behaviors that are the focus of interventions. It predicts successful outcome. The inability to cooperate is one of the core deficits of personality disorder (Livesley, 2003), especially BPD. Consequently, the APA Practice Guideline on borderline personality disorder (2001) stresses the importance of a pre-therapy contract phase. Every major model of psychotherapy employs some “contract.” The contract has a containing function that reduces the probability of crises getting out of control and endangering or destroying the therapeutic relationship. It does so by defining roles and goals, anticipating threats to therapy, specifying responses to threats, and describing consequences of non-compliance (Yeomans et al., 1992). All therapies require a modicum of cooperation however, including honesty, regular attendance, and collaboration. Refractory borderline patients, however, do not present this way; they have multiple deficits: the chaotic-impulsive ones lack the minimal structure, the abused ones are too fearful, the hostile ones lack patienthood. Therapy therefore sometimes cannot even make a start, or, as with “Rachel”and “Kelly,” comes to a premature end. When treating refractory patients, one needs a different perspective. A rehabilitation perspective Paris (2003) states that personality disorders have all the features of a chronic illness: they emerge early in life, have a significant heritable component, affect functioning over many years, and, as with other chronic diseases, psychosocial factors act as precipitants for illness. If this is true for personality disorders in general, it is certainly

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true for refractory BPD: these patients have complex, early symptomatology, multiple, long-standing problems in every area of life, few resources and a personal style that deters others from them. Their condition is therefore best conceptualized as a severely disabling, chronic illness. Classical psychotherapy does not particularly suit this kind of psychopathology. A rehabilitation perspective is more appropriate to the needs, deficits, and capabilities of these patients (van Luyn, 2003). Rehabilitation In rehabilitative approaches cure is not the objective: the goal is to ameliorate rather than eliminate symptoms and to help patients to achieve more adaptive ways of coping with handicaps and deficits. For instance, slowly and gradually teaching BPD patients to “own their own anger” (Gunderson, 2001), helping them understand that it is their own impulsive anger that produces anger in others, and – on a more practical level – not communicating by email or sms when angry may help them continue relationships. Rehabilitation is necessarily eclectic because no single method or approach encompasses the complexities of chronic patients. Therapies come to an end while rehabilitative approaches do not. They offer continuing care: like a good parent, these programs “hold,” “let go,” but always “hang around.” Gunderson (2001) differentiates “therapy” from “treatment.” In therapy, there is at least intermittent collaboration with shared goals and reciprocity whereas treatment tends to be passively received. Therapy has to be acquired, treatment is offered. The therapy–treatment dichotomy is not absolute – there is much in between – but it is a useful way to think about the management of refractory cases. Rehabilitation programs focus on the treatment side of the continuum: they offer more than ask, they accept more than push, act more than wait, and stay more than leave. They are flexible, with a strong emphasis on building positive relationships, but are also well structured and consistent. Treatment from a rehabilitation perspective requires a setting that is not restrictive. A specific type of intensive outpatient treatment – based on what is often referred to as “assertive community treatment” (ACT) – is probably the best attainable level of care for these patients. Assertive community treatment Based on the pioneering work of Stein and Test (1980), and developed for patients with chronic psychotic conditions, ACT programs offer long-term commitment, continuity of care, proactive and outreach interventions, life skills training, and assistance in all major areas of life. They integrate patient information, coordinate activities involving other agencies, such as legal, social welfare, medical, and so on, and are easily accessible for the patient. ACT programs contain multiple disciplines

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and heavily rely on staff teamwork. Staff members are not just brokers of care but the main providers of care. For the most difficult patients, they offer “clinical team case management,” which means that several professionals are involved with the same patient. In contrast to the fixed time schedules of psychotherapy, this guarantees a much greater availability of service. For patients with severe BPD, as for patients with chronic psychoses, clinical team case management may dilute strong feelings of transference. For their caregivers, the system helps to dilute the countertransference, especially feelings of impotence and/or severe irritation. Links (1998) reviewed the literature on the effectiveness of this model for Axis II patients. He found that the effectiveness of ACT models in this population could be compared to its effectiveness for patients with chronic psychotic disorders. Rates and days of hospitalization decline, satisfaction with these programs and compliance with medical prescriptions increase, and there is some evidence for decreased legal problems. The impact on symptomatic improvement, particularly the effect on affective, cognitive, and behavioral symptoms, was less clear. The effects of ACT on social functioning and social network seemed to be positive but needed further study. Links’ overall conclusion was that these intensive outpatient programs have potential for personality-disordered patients but that they need to be tailored to their specific needs. Intensive outpatient programs for refractory BPD To adapt to the needs of refractory borderline patients, ACT-like intensive outpatient programs should: (1) actively engage patients to the program and safeguard a consistent frame; (2) acknowledge the need for hospitalizations but integrate them in an overall plan; (3) offer systems support; and (4) support staff. Engaging the refractory patient The development of a collaborative alliance is an essential, generic aspect of any good treatment for PD (see Livesley, Chapter 13). Engaging refractory BPD patients is even more important, because of their deep distrust and rejection-eliciting behavior, chaotic lives, and multiple problems. They do not commit to treatment out of themselves, but have to be engaged. The first task in engaging the refractory patient is to assign a case manager or primary clinician. According to Gunderson (2001), the major responsibilities of the primary clinician are to identify needs and develop a treatment plan, monitor safety and progress, coordinate treatment modules, and provide psychoeducation. The major responsibility, however, is to engage the patient in a contractual alliance and establish the therapeutic framework: “For primary clinicians . . . the development

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of an alliance is a mandate, not an option” (Gunderson, 2001). If the patient enters the delivery system through a series of crisis contacts, the clinician’s first tasks are to build motivation for a more continuous engagement to the program, to coordinate activities and create some continuity in seemingly separate interventions, and facilitate some accumulative impact of these interventions over time. If successful, the process of formally engaging the patient with the program can begin. Engaging refractory patients takes effort and patience because their level of cooperation is often on the edge of what a contractual alliance requires. The primary clinician’s job then is to “shape” an alliance by explaining, giving hope and perspective, empathizing, validating, being and staying there, and also by confronting, formulating conditions, and setting limits. With refractory patients, it takes an experienced clinician to give the right dosage of support and confrontation, and contain the strong affects and suicidal threat. To maintain their engagement, these intensive programs need strategies based on the principle of “split treatment” (Gunderson, 2001). Split treatment Split treatment is an approach in which a patient is treated by at least two professionals or two modalities, or any two relatively independent components; for example, a combination of case manager and psychiatrist, or individual and group therapy. According to Gunderson any borderline patient who makes extensive use of splitting mechanisms should be treated according to this principle. Compared to the average BPD patient, refractory ones have more psychopathology, more severe split-off views of the world, and hence often need more boundaries. Having the same professional offer support, teach, help understand, and set limits is too much to ask. Refractory patients need what traditional ACT programs called “clinical team case management”: assigning several professionals to the same patient, a strategy ACT programs developed for their most difficult patients. Split treatment strategies help to protect the treatment against premature break-up and dropout because frustrations that cannot be dealt with by one professional can be contained and discussed with the other. Split treatment also helps to dilute strong feelings of transference and countertransference. Ideally, intensive programs for refractory patients deploy three types of clinicians. One type of clinician – often well-trained nurses and job coaches – assists the patient with the tasks of everyday life, primarily adopting a supportive, problem-solving, and teaching mode. The second is the primary clinician – often a psychiatrist – whose role evolves into a more administrative one: monitoring safety, monitoring progress, implementing treatment recommendations, and setting limits. Here the major role is maintaining the frame of treatment. A third professional is a “neutral

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psychotherapist,” a clinician unfortunately relatively rare in ACT-like programs, probably because psychotherapy tends to be less committed to the most severely disabled psychiatric patients. The “neutral psychotherapist” Whereas the other professionals function more on the treatment side of the treatment–psychotherapy continuum, the psychotherapist tries to engage the patient in therapy. Since the psychotherapist is not responsible for the overall treatment plan and administrative issues, he or she is in a neutral or conflict-free position that permits a non-controlling and exploratory stance designed to help the patient understand what happens, why things happen the way they do, what motivates behavior – the patients’ behavior as well as the behavior of others – and enhance mentalization (Bateman and Fonagy, 2004). The therapist has to “ . . . question continually what internal mental states both within his patient and within himself can explain what is happening now” (Bateman and Fonagy, 2004). By linking external events to internal states, the patient is helped to understand the self in relationship to the world and vice versa. The therapist’s task is to explore conflicts and help identify different perspectives and other ways of solving problems. This requires an active and interactive approach. Initially, in this process of “psychotherapeutic treatment,” the therapist takes a more “treatment-stance”: he or she is supportive, explains therapy issues and roles, and provides some psychoeducation, for instance explaining transference issues, offering examples of what he or she might do to offer a more psychotherapeutic stance. The patient’s task is to attend sessions and tolerate the therapist and the process. If the patient refuses sessions, the therapist carefully explores why and what went wrong, but accepts and offers a new appointment. The intention is to help the patient to understand gradually that therapy “might work,” and to “seduce” the patient into the reciprocal effort of therapy. If skilfully done, dependency increases. With these patients, where attachment problems are part of the core pathology, increasing dependency is a major step forward: it implies being able to turn to another human being when under stress; to trust another; to tolerate feelings of intimacy; to experience that “self,” however fragile, does not dissipate in the presence of others. If the patient commits himself or herself, the balance gradually shifts towards the therapy end of the continuum. More mature forms of cooperation then may develop. Integrating hospitalization admissions Given the chronic and sometimes perilous nature of refractory BPD, there needs to be a longitudinal plan that covers hospitalization (van Luyn, 2003; van Meekeren,

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2000). Patients with severe BPD extensively use inpatient treatment. The APA Guideline for the treatment of BPD (2001) recommends brief hospitalization when there is a high risk of suicide, severe self-mutilation, serious high-risk behavior, or danger to others that cannot be managed in any other way. Long-term admission is recommended when these threats persist and do not respond to therapy. Hospital treatment for BPD is, however, contentious. Outcome studies fail to offer strong evidence for its efficacy (McGlashan, 1986). Paris (2003) mentions the lack of evidence that inpatient treatment is effective in managing parasuicidal behavior or threats, and Livesley (2003) also states that there is little evidence for extended admissions. He describes the difficulty of breaking the cycle of crises and repeated admissions. In his view, inpatient treatment is a matter of necessity, not indication. Although the effect of extended inpatient treatment has never been systematically studied, it may have a significant negative impact. It often does not help patients to manage life problems but rather facilitates avoidance. In patients with chronic suicidality (Paris, Chapter 7), the hospital routine of constant care and close observation may even reinforce the very behavior it tries to control. Regression frequently occurs, creating additional management problems. In refractory patients, hospitalizations are part of the deal: sometimes they cannot be avoided, sometimes – when severe danger dominates the clinical picture – they are even mandatory, and sometimes they should not be avoided because they are useful. The adverse consequences of admissions can be reduced if they are part of an overall treatment plan that describes the overall, ambulatory trajectory, anticipates emergencies and prefers ambulatory interventions as the first option when crises arise. If hospitalization is necessary, outpatient treatment is temporarily interrupted but resumed as soon as possible. Goals and duration of the inpatient period are as much as possible agreed upon. Stays should be limited to a few weeks because prolonged admissions tend to produce more problems than they solve. Preferably, inpatient and outpatient services are part of the same institute, so they can develop one joint policy for these difficult to treat patients.

Indications to hospitalize Situations that may warrant hospital treatment are: 1. Severe suicide attempts that strongly upset the patient, relatives, and caregivers. Especially with refractory patients, both relatives and caregivers need a respite occasionally from their responsibilities to the patient to prevent avoidance reactions and burn-out, and safeguard their long-term commitment to the patient. The time-out the hospital offers can be used to evaluate and possibly change the treatment plan.

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2. Lack of impulse control that is so dangerous or frequent that outpatient treatment is insufficient. Stabilization and attachment then are the primary objectives. 3. A severe accumulation of real-life problems (escalating conflicts with relatives, legal problems, problems with housing or social welfare, loneliness) that exceeds a patient’s internal and external resources and threatens to augment symptomatology. At these times it may be sufficient to acknowledge and validate their needs and help them to start to problem-solve. If this does not work, hospitalization may be the intermediate step. Hospitalization offers the holding environment that temporarily releases them from their responsibilities, and helps them solve their problems in a structured way. Refractory patients do not express their needs in a direct way. Sometimes they themselves ask for an admission; most often, however, they express suicidal ideas, “do not trust themselves anymore” or report an increasing urge to self-mutilate. If in these situations of angry despair needs are not met, and admission is refused, feelings of abandonment increase, leading to demanding and escalating behaviors that ultimately often are reinforced by admissions, which is a contingency any behaviorist would dislike.

Facilitating hospital discharge Refractory patients may be so continuously dangerous or self-destructive that longterm hospitalizations cannot be avoided. With severely abused, anxious, and mistrustful patients, long-term hospitalization need not be all bad and may offer opportunities to learn how to ask for help when in pain, experience another person as both controlling and caring, and develop affective alliances with inpatient staff. With very chaotic patients containment and daily routines offer some structure which enables some emotional stabilization and at least opens the possibility for treatment. It is a difficult enterprise though. Containment – external control – is the most concrete form of holding that alleviates the responsibility for self-control (Gunderson, 2001) and brings some relief. However, most borderline patients also fear being controlled. Extended hospitalizations therefore create a volatile situation that fuels conflicts with staff (Drum and Lavigne, 1987). Linking patients to intensive outpatient programs – or better still, linking outpatient staff to inpatients – can be effective in preventing destructive interactive patterns and facilitating discharge. While hospitalized, outpatient nurses may assist the patient to find a place to live, develop meaningful community-based activities, and support the patient while on leave from hospital. The outpatient-based, neutral psychotherapist may help the patient understand what happens, in their and others’ minds, and how their behaviors might impede or facilitate leaving the hospital. Not being in charge of leaves, discharge, seclusion, and restraint may enable the therapist to avoid power

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struggles and to develop the hope that a more normal life is possible. Hope is an important protective shield that may help to reduce suicide risk. A major goal of linking these hospitalized patients to outpatient programs is to ensure continuity of care and develop consistency. Having (at least in part) the same professionals assist the patient inside and outside the hospital may deepen the attachment of these patients to their caregivers, and help them to accept their fundamental dependency needs. Since many suicides in BPD patients occur just after discharge or before mandatory discharge, integrated programs may help to prevent suicide. Having an outpatient psychotherapist involved in inpatient care ensures that therapy can continue after discharge. This helps to reduce dropouts: Waldinger and Gunderson (1984) showed that more severe BPD patients were more likely to remain in psychotherapy that began during inpatient stays. Systems support and systems interventions Life is difficult for the refractory patient; living with them equally so. Natural systems often are exhausted because the lives of family members and other supportive individuals are dominated by the patient’s problems and psychopathology. Feelings of shame, guilt, despair, and repressed aggression are the rule. Often family members have been blamed by the mental health system itself as being not caring enough or too caring. All these systems need support, information, psychoeducation, and de-blaming to help them continue their relationships and care. They need help finding the right balance between intimacy and distance, and need assistance when crises develop. Sometimes it is possible to restore broken relations, even with parents who – for their own reasons – once were neglectful. If they are able to take responsibility for their failure, rebuilding relationships is possible. Restoring relations often needs several individual sessions with parents or siblings before conjoint meetings are possible. The main task of the therapist here is to listen to the life-stories, validating them, deblaming, giving psychoeducation, and reinforcing realistic expectations. Conjoint sessions should preferably be held if new object relations are deemed possible. If not, old destructive patterns may be reinforced, possibly leading to renewed feelings of abandonment, loss of hope, and suicidal behavior. Using oneway mirrors can be very useful to start these conjoint meetings: one therapist interviews the parent about his/her past relationship and experiences with the child, his/her present wishes, fears and hopes, while another watches and listens with the patient behind the mirror. Afterwards the same is done but the other way round. It is important to help patients and their relatives regulate their strong affects in these meetings. Blocking direct (and non-verbal) communication through the use of one-way mirrors does so; it facilitates communication and the exploration

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of respective motives, wishes, and feelings. If these sessions are constructive, more interactive meetings can be held. If the patient is still part of an ongoing abusive system, it is an issue that should be addressed in the patient’s individual therapy. Patients often need straightforward information about what is normal in (healthy) relationships, since their predominant experiences are of dysfunctional relationships. It is important to validate their justifiable feelings of pain, distrust and anger, and to help them set limits and help them separate. Team support

Treating refractory patients is difficult and stressful. Clinical teams (especially inpatient nurses, because of their intensive exposure to these patients, but also professionals from the community) need support, and education about the disorder and its treatment. It is a primary task if they are to manage these patients effectively. To enable the containment of the emotionality and reactivity of refractory patients, teams need opportunities to air and discuss the wide range of feelings that are evoked. Discussing, validating, and framing these feelings helps prevent caregivers from acting out like their patients. The best way to support these teams, however, is to offer practical tools and a common language with relatively simple concepts to analyze what happens between them and their patients. Young (1999) offers such concepts from his schema-focused approach. His concepts can be used to help daily caregivers maintain consistency, and partly accommodate their behavior to the patient’s state of mind. There is no need to adopt his complete model. Young distinguishes five alternating “modes” or states of mind of borderline patients; he describes their typical interactive patterns, countertransference pitfalls, and a preferred way of approaching the patient. 1. The angry child, a mode in which the patient is angry and demanding. Wishes are experienced as needs, and presented in forceful ways, sometimes even using suicidal threats. Caregivers typically tend to feel manipulated, leading to escalating behaviors and rejection. A constructive limit-setting stance is required, coupled with support and validation. More important is to look for constructive ways in which “needs” can be met. 2. The abandoned child, the mode of a desperate child who feels helpless, hopeless, and left alone. It is a mode that is often hidden behind the angry child. The patient in this mode typically evokes sympathy and protection. The countertransference risk is overprotection and the wish to “save” the patient, paving the way for impotence and rejection if efforts fail. The preferred stance is to help the patient identify, accept, and satisfy his or her need for care and security. 3. The detached protector, a mode in which the patient seemingly adjusts and behaves well. He or she is detached, however, denies or represses feelings, and

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avoids contact with others. When the patient presents in this mode, caregivers typically feel relieved and also tend to avoid contact, leaving the patient alone with intolerable feelings and an increased risk for suicidal or self-destructive behavior. The best approach is to engage the patient and carefully address what is being avoided. 4. The punitive parent, a very persistent mode in which the patient feels completely disentitled, having no right to express any need. The clinical picture is dominated by extreme self-hate, self-criticism, and self-harm as a form of punishment. Countertransference reactions are often dominated by feelings of impotence. The preferred stance is to empathize with the patient, raise objections, and help him or her to find a different perspective. 5. The adult, a mode in which the patient displays trust in self and others, accepts help, and presents realistic goals and wishes. The countertransference risk is that caregivers expect more of the patient than is possible. The best approach is to praise the patient (and one might say “praise the day”), and not convey that one now expects more. The advantages of Young’s concepts are that they are a useful guide in team discussions, and also that the same language is readily understood by patients and relatives. Finally, offering team support also implies a discussion of the risks that are inevitably part of treating severe patients. It is important for teams to realize that – as noted by the Guideline for the treatment of BPD (2001) – these patients may commit suicide even if given adequate treatment. If this reality is not accepted, caregivers will react with fearful repression or regression-reinforcing compliance to any suicidal threat.

Conclusion Management of severe refractory borderline patients is best done from the perspective of psychiatric rehabilitation. A psychiatric rehabilitation approach acknowledges the deficits of these patients and their chronic condition. It does not act on the assumption that there may be an end to the disease and treatment: rehabilitation is disease management and engages its patients in a long-term commitment. Management of severe cases is teamwork. It requires a comprehensive and eclectic approach that crosses traditional borders between inpatient and outpatient care, and between psychiatry and psychotherapy. If imbedded in a comprehensive, overall supportive program, psychotherapeutic approaches may be viable with these patients, creating opportunities to acknowledge and accept dependency needs, discuss and work through painful and difficult emotional issues, and address core schemata.

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Clinical experience indicates that severely abused and chaotic and impulsive patients may respond well to these programs, leading to decreases in suicidal acts and threats, increased quality of life, independent living, and most importantly to patients starting to “own their own anger” (Gunderson, 2001). Anger does not have to lead to dropout or separation in these long-term split-treatment programs; anger, and impulsive behavior can be discussed the moment the storm is over. Without fundamentally changing core psychopathology, this consistent frame gradually enables patients to cope better with their impulsivity and affective instability. Not projecting anger onto others reduces conflicts with relatives and caregivers. Maintaining relationships, keeping a job, continuing to study may become possibilities. These developments in turn create more stability of the self which opens the opportunity to attend to and possibly benefit from specific group-oriented programs; for instance, skills-training programs on affect regulation, or substanceabuse management. Early in their treatment history these patients often lack the motivation and the internal and external structure these programs require. For some patients sheltered living becomes possible, even where they were too difficult to handle before. Usually outpatient programs continue their engagement with patients when they move to these housing facilities. Hostile patients are more difficult to manage and require more active outreach. Damage control may be the only feasible intervention, although in the long run this may help patients to accept help. When antisocial features predominate, active outreach services are no more successful than other programs. Gunderson, discussing the poor global assessment of functioning scores of improved patients from the CLPS study (the APA conference, New York, 2005), stressed the importance of developing more rehabilitation programs. Paris (2003) advocates the rehabilitation model for BPD in general. In the long run, the best approach to managing refractory patients is to prevent borderline patients from actually becoming refractory. Integrated, rehabilitative programs might just do that. R E F EREN CES American Psychiatric Association (2001). Guidelines for the treatment of borderline personality disorder. Am J Psychiatry Suppl 157: 1–52. American Psychiatric Association (2001). Practice Guidelines for the Treatment of Patients with Borderline Personality Disorder. Washington, DC: American Psychiatric Press. Bateman, A. and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford: Oxford University Press. Betan, E., Heim, A. K., Zittel Conklin, C. and Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: an empirical investigation. Am J Psychiatry 162(5): 890–898.

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Severe cases: the refractory borderline patient Drum, P. and Lavigne, G. (1987). Extended state hospital treatment of severely impaired borderline patients. Hosp Commun Psychiatry 38(5): 515–519. Giesen-Bloo, J., van Dyck, R., Spinhoven, P. et al. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 63(6): 649–658. Gunderson, J. G. (2001). Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Publishing. Gunderson, J. G., Daversa, M. T., Grilo, C. M. et al. (2006). Predictors of 2-year outcome for patients with borderline personality disorder. Am J Psychiatry 163 (5): 822–826. Hinshelwood, R. D. (1999). The difficult patient, the role of “scientific psychiatry” in understanding patients with chronic schizophrenia or severe personality disorder. Br J Psychiatry 174: 187–190. Kernberg, O. F. (1984). Severe Personality Disorders. New Haven, CT: Yale University Press. Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Links, P. S. (1998). Developing effective services for patients with personality disorders. Can J Psychiatry 43: 251–259. Links, P. S., Heslegrave, R. J., Mitton, J. E. et al. (1995). Borderline personality disorder and substance abuse: consequences of comorbidity. Can J Psychiatry 40: 9–14. Livesley, W. J. (2003). Practical Management of Personality Disorder. New York: The Guilford Press. Luyn, J. B. van (2003). De extra moeilijke borderlinepati¨ent, het prototype van een moeilijk mens. In C. A. L. Hoogduin and W. A. Hoogduin (eds.) Omgaan met Moeilijke Mensen. Nijmegen: Cure and Care Publishers. McGlashan, T. (1986). The Chestnut Lodge follow-up study. III: Long-term outcome of borderline personalities. Arch Gen Psychiatry 43, 20–30. McGlashan, T. H., Grilo, C. M., Sanislow, C. A. et al. (2005). Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders. Am J Psychiatry 162 (5): 833–835. Meekeren, E. van (2000). De regievoering in de behandeling van borderlinepati¨enten; context en eenheid van behandeling. Dth 20 (3): 216–228. Monroe, S. M. and Simons, A. D. (1991). Diathesis-stress theories in the context of life stress research. Psychol Bull 110: 406–425. Paris, J. (2003). Personality Disorders over Time, Precursors, Course and Outcome. Washington, DC: American Psychiatric Publishing. Perry, J. C., Banon, E. and Janni, F. (1999). Effectiveness of psychotherapy for personality disorders. Am J Psychiatry 156: 1312–1321. Pfohl, B. and Blum, N. (1991). Obsessive compulsive personality disorder: a review for DSM-IV. J Pers Disord 5: 363–375. Shea, M. T., Pilkonis, P. A., Beckham, E. et al. (1990). Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry 147: 711–718.

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Bert van Luyn Skodol, A. E., Pagano, M. E., Bender, D. S. et al. (2005). Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med 35 (3): 443–451. Stein, L. I. and Test, M. A. (1980). Alternative to mental hospital treatment. Arch Gen Psychiatry 37: 392–397. Stone, M. H. (1990). The Fate of Borderline Patients: Successful Outcome and Psychiatric Practice. New York: The Guilford Press. Stone, M. H. (1993). Long-term outcome in personality disorders. Br J Psychiatry 162: 299–313. Stone, M. H. (2001). Natural history and long-term outcome. In W. J. Livesley (ed.) Handbook of Personality Disorders: Theory, Research, and Treatment. New York: The Guilford Press. Waldinger, R. J. and Gunderson, J. G. (1984). Completed psychotherapies with borderline patients. Am J Psychotherapy 38: 190–202. Yeomans, F. E., Selzen, M. A. and Clarkin, J. F. (1992). Treating the Borderline Patient: A ContractBased Approach. New York: Basic Books. Young, J. E. (1999). Cognitieve Therapie voor Persoonlijkheidsstoornissen. Houten/Diegem: Bohn Stafleu van Loghum. Zanarini, M. C. (1993). A two-site year follow up of borderline patients and axis I controls. Paper presented at the International Congress on the Disorders of Personality, Cambridge, MA., September 1993. Zanarini, M. C., Frankenburg, F. R., Hennen, J. et al. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 160: 274–283.

11 11

Dangerous cases: when treatment is not an option J. Reid Meloy and James A. Reavis

There are those who walk among us that have no conscience. They mouth certain feelings, but have no emotion. They do not bond to any living creatures. Because of their chronic emotional detachment and often sadistic impulse, they aggress without inhibition when their desires are thwarted. Their sole relational goal is to dominate their objects. They are the consummate “intraspecies predators” (Meloy and Meloy, 2002). Although this sounds like fiction, it is not. Each of these assertions is supported by abundant empirical evidence. We are describing, of course, the psychopathic subject in his most severe, ontogenetic form. Psychopathy research is burgeoning, and over the past decade the world scientific literature has yielded over a thousand studies.1 When psychopathy enters the consulting room, for the psychotherapist or psychoanalyst it is a sign of danger. The nature of the beast We theoretically conceive of psychopathy as a genotype, much like schizotypy (Raine et al., 1995) – a stable constellation of biologically predisposed traits and behaviors which exists in various members of our species. In the context of certain social and cultural norms, psychopathy has different levels of phenotypic expression. For example, best estimates suggest that psychopathy in its most severe form is present in 1% of the world’s population (Hare, 2003). However, the prevalence of antisocial personality disorder (ASPD), as most recently defined in DSM-IV-TR (American Psychiatric Association, 2000), varies considerably across cultures. In the United States, ASPD is found in 5.8% of males and 1.2% of females (Kessler et al., 1994) for an average general population rate of about 3% (American Psychiatric Association, 2000). In Taiwan, ASPD rates are 20 times less than in the United States, likely a corollary of a social emphasis on collectivism versus individualism in each respective  C Cambridge University Press 2007

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country (Reavis, 1998). The practical implications of these theoretical assertions and empirical findings are that the clinician should regard psychopathy, if present in a patient, as a stable, immutable aspect of his or her personality that will range in severity from mild, to moderate, to severe; and although most likely to be present in the context of a diagnosable ASPD – admittedly a rough categorization – it may also be noticed in the presence or absence of other DSM-IV-TR personality disorders. We illustrate this with a case from the first author’s files. Case A Dr A was hired as a forensic psychiatrist in a publicly funded court clinic to perform evaluations of subjects in custody and testify in the California Superior Court. His resume was impeccable, although on interview his mannerisms were unusual and he largely avoided eye contact. As soon as Dr A began working, however, problems arose. Court personnel complained about his lateness in filing his evaluations and his unreliable and often bizarre testimony. After 2 months of incessant complaints, he was terminated from his position while on probation. Several months later, his girlfriend won a custody battle for their young daughter, as well as a large financial settlement. Her testimony at the civil hearing was dramatic. She recounted two incidents: she and her Hispanic nanny were detained for many hours at an international airport in the United States following an anonymous phone call to authorities which indicated that the nanny was trying to illegally enter the country. She was not. The second incident was even more disconcerting. Dr A invited his girlfriend over to his home during their civil litigation, ostensibly to attempt some kind of reconciliation. He romanced her, and she consented to go to bed with him. Once in bed, he turned on the television set which displayed a police video of a sexual homicide crime scene. He told her, “this is what happens to bad girls.” At the time he was consulting with the local prosecutor’s office on the sexual homicide case. Within 6 months of the settlement, Dr A was arrested for attempting to contract with an undercover police officer to have his girlfriend murdered. He was convicted of solicitation for murder, lost his medical license, and was sentenced to prison. Although he offered to provide medical services to other inmates, his generosity was declined. Prison psychologists evaluated him and diagnosed Dr A as a psychopath with prominent narcissistic and schizoid features. He successfully served his prison sentence and subsequent parole, and appears to have relocated to another state in the United States.

Dr A, although he completed the training and education to legally treat mentally and emotionally ill individuals, was an untreatable specimen himself. Other writers have documented the lengths to which professional guilds will go to protect psychopathic members of their own professions (Stewart, 1999; Vise, 2002). Psychopathy should concern clinicians for three reasons: when it is severe, treatment is a waste of time and effort, and may make the character pathology worse;

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the patient is likely to be emotionally dangerous; and the patient may be physically dangerous and pose a real threat to the clinician and others. There is no body of controlled treatment outcome research, and there is, at present, no mental health treatment for psychopathy. These findings do not preclude the eventual discovery of an effective treatment regimen, but they do invite clinical caution and therapeutic skepticism if psychopathy is diagnosed in a patient seeking treatment. There are, moreover, several research studies which suggest that mental health treatment, when applied to the severely psychopathic patient, may increase his risk of future criminal behavior (Rice et al., 1992; Seto and Barbaree, 1999). In a large prospective study of offenders in England and Wales, Hare et al. (2000) found that psychopaths with substantial interpersonal and affective deficiencies recidivated at a much higher rate if they had received treatment than if they had not. D’Silva et al. (2004) noted, however, that a negative treatment effect has not been established, and there is only one study of psychopathy and its effect on treatment in a nonforensic sample of patients (Skeem et al., 2002); in the Skeem study, psychopathy did not diminish the treatment effect of traditional mental health care in reducing subsequent violence over the short term. Nevertheless, clinicians should keep in mind the absence of positive effects, and the presence of some negative effects of mental health treatment on psychopathy, and proceed with great caution. The emotional danger of the psychopathic patient is a less obvious, but still serious issue. It often emerges from two inherently conflicted positions. On the one hand, the psychopath wishes to dominate his objects, and will use whatever interpersonal skills are at his disposal to do so. On the other hand, the clinician assumes that a patient has the wish and the capacity to form a therapeutic relationship based upon trust and a motivation to get better. Dominance–submission and reciprocal affection do not mix, and the clinician may become deeply disturbed as he or she gradually, or suddenly discovers the mendacity of their psychopathic patient. The emotional life of the psychopath is developmentally pre-oedipal and pathologically narcissistic. Psychopaths do not experience emotions such as sympathy, empathy, gratitude, shared joy, guilt, or remorse. Such feelings necessitate whole object relatedness: the ability to mentally represent self and others as whole, real, meaningful, and separate individuals. Although not yet empirically measured in the childhood psychopathy literature, he may not even develop the rudimentary skills of sharing and exchanging evident in young toddlers who are just beginning to understand the presence of a separate other (Gacono and Meloy, 1994; Meloy, 1988, 2001). His emotional life is instead characterized by part self and part object relations and accompanying feelings of boredom, exhilaration, frustration, excitement, shame, envy, and rage. Others are purely extensions of the self (Meloy, 2001), only present intrapsychically and interpersonally as sources of immediate frustration or

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gratification. In other moments they do not exist, especially as constant objects of gratitude or concern. The clinical problem is that the psychopathic patient will often imitate the more mature emotional states that he observes the psychotherapist wants him to feel. He does not identify the nuances of the clinician’s emotions and desires for him through empathy, but through the vigilant activity of a predator studying the behavior of his prey. Psychopaths in the laboratory show enhanced orienting responses in certain reward situations when compared to normals (Hare, 2003). We also know through functional neuroimaging studies that they do not process emotion the way normal individuals do (Kiehl et al., 2001), and clinically appear to be limbically disconnected (Meloy, 1988). Case B Patient B, a severe psychopath, was misdiagnosed as a narcissistic personality disorder and began intensive, psychodynamic psychotherapy. As the weeks passed, the clinician became aware that his assumptions that patient B – despite his grandiosity and sense of entitlement – experienced anxiety, formed attachments, and had a conscience were wrong. These prerequisites for successful treatment were absent. Instead, the patient became irritated, evasive, or gave absurd statements when asked to describe certain emotions he reportedly felt. The clinician sought supervision to address his disturbing recognition that the perceived emotions in his patient were only his wishful projections. Psychological testing done by a consulting psychologist confirmed his suspicions.

The physical danger of the psychopathic patient should not be underestimated, even in the absence of a history of violence. There are many case studies which document both the affective (sudden, reactive, emotional) and predatory (planned, instrumental, emotionless) violence of psychopathic males who maintained a veneer of familial bliss and occupational success for several years prior to their committing murders (Cahill, 1986; McGinniss, 1983; Rule, 1980). Often the motivation for the first killing is quite banal. In a recent California case, People v. Scott Peterson, a young man with many of the hallmarks of the core personality characteristics of psychopathy murdered his pregnant wife and attempted unsuccessfully to dispose of her body in the San Francisco Bay. He killed for unknown reasons, but was having an affair at the time. Peterson was eventually convicted and sentenced to death. The reporters who covered the trial were perplexed and disturbed by his complete absence of emotion throughout his court appearances. When he arrived on death row at San Quentin, he was overheard to remark, “what an adrenaline rush!” (first author’s files). Both of these behaviors would be consistent with a chronic emotional detachment and a hunger for autonomic arousal noted in the clinical and empirical psychopathy literature (Hare, 2003). In forensic research the relationship between psychopathy and violence has been well documented. When compared to non-psychopathic criminal offenders,

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Superficial Grandiose Deceitful Lacks remorse Lacks empathy Doesn’t accept responsibility Impulsive Poor behavioral controls Lacks goals Irresponsible Adolescent antisocial behavior Adult antisocial behavior

psychopathic criminals are more likely to be violent (Williamson et al., 1987), use a weapon (Hare et al., 1988), target strangers, arouse to sadistic sexual and non-sexual themes (Levenston et al., 2000), continue to be violent as they age (Hare, 2003), violently fail when conditionally released to the community (Hare, 1981), and escape from forensic hospitals (Gacono et al., 1997). The presence of psychopathy is the strongest predictor of violence in both forensic (Hare, 2003) and civil mental health settings (Monahan et al., 2001), and is the second strongest predictor of sexual reoffending (Harris et al., 2001) – the first being sexual arousal to deviant stimuli. Research on the so-called white collar or successful psychopath, however, is in its infancy (Babiak and Hare, 2006), and other non-violent forms of aggressive predation in this population, such as economic exploitation of others, have yet to be measured.

Diagnostic issues Psychopathy can be measured in a reliable and valid manner utilizing one of the Hare instruments (Hare, 2003). Table 11.1 lists the 12 screening criteria for psychopathy (PCL:SV, Hart et al., 1995) and is a highly correlated short form of the 20-item Psychopathy Checklist-Revised (PCL-R) (Hare, 2003). The Hare instruments are quantifiable observational measures based upon clinical interview and records review, and should only be used by a qualified mental health professional with appropriate training. We recommend the screening version for clinical practice when psychopathy is suspected. It does not require the time commitment of the PCL-R and provides the psychotherapist with an objective measure of his or her clinical concerns. Further

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psychological testing may be warranted by elevated scores on the PCL:SV (>13). Gacono and Meloy (2002) provide a comprehensive guide for assessing psychopathy utilizing various tests and measures. Unfortunately, the DSM-IV-TR (American Psychiatric Association, 2000) gives little help in the diagnosis of psychopathy since the ten personality disorders – especially Cluster B – are largely polythetic, behavioral criteria sets that have poor discriminant validity and show a comorbid relationship with many other Axis I conditions. In criminal populations, however, the severity of psychopathy does closely correlate with the number (1–7) of ASPD criteria in DSM-IV-TR that are met. In public and private non-forensic mental health settings, however, the psychopathic patient may have no overt history of criminality or violence, yet over time evidence both the interpersonal (glibness, grandiosity, pathological lying, manipulation) and affective (lack of remorse or guilt, shallow affect, callousness, failure to accept responsibility) deficiencies that are the core personality traits of the disorder. Psychological testing in such settings is critical, even though it is not often utilized by psychotherapists and psychoanalysts. The Rorschach, for example, can save a clinician many hours of wasted effort when employed as a prognostic telescope of treatment outcome (Gacono and Meloy, 1994; Weiner, 1998). An early decision not to treat based upon competent testing also avoids the sticky wicket of transference and countertransference if such a decision must be made weeks or months into the therapeutic work. Countertransference phenomenon The clinician’s reactions to the psychopathic patient often provide sensitive emotional indicators of the latter’s psychopathology, and do not necessarily indicate neurotic conflict in the psychotherapist. In fact, such reactions may imply evolved adaptive strategies that have been developed to protect ourselves against the predation by such individuals (Meloy and Meloy, 2002). Such reactions should not be documented in the clinical record since they will be viewed by others as admittedly subjective, but they can provide an impetus for further objective testing to measure the degree of psychopathy in the patient of concern. Lion (1978), Symington (1980), Strasburger (1986), Meloy (1988, 2001), and Gabbard (1994) have identified eight common countertransference reactions which are listed in Table 11.2. We have also added a ninth. Therapeutic nihilism

Lion (1978) used this term to describe the clinical rejection and condemnation of all patients with any history of antisocial behavior as being completely untreatable. Instead of carefully evaluating the patient who has some psychopathic traits for

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1. 2. 3. 4. 5. 6. 7. 8. 9.

Therapeutic nihilism (condemnation) Illusory treatment alliance Fear of assault or harm Denial and deception Helplessness and guilt Devaluation and loss of professional identity Hatred and the wish to destroy Assumption of psychological complexity Fascination and sexual attraction

evidence of conscience, anxiety, attachment, and conflict, the clinician sees him as a pariah and devalues him, concordantly utilizing a psychological defense that is very common in psychopathy (Racker, 1968). The clinician does to the patient what the patient does to others. Symington (1980) referred to this same countertransference reaction as condemnation. Illusory treatment alliance

The opposite reaction in the clinician is the illusion that there is a treatment alliance with the patient when, in fact, none exists. As illustrated in the case B vignette above, such perceptions are often a product of the wishful projections of the clinician and the imitative skill of the patient. Meloy (1988) called this malignant pseudoidentification. Behaviors during psychotherapy suggest that such an alliance should be skeptically viewed, especially if the patient’s psychopathy is moderate to severe. The psychopath is a chameleon, and early psychoanalytic papers on his propensity to imposture are elegant and insightful (Greenacre, 1958). Bursten (1973) described the “manipulative cycle” in the psychopathic patient wherein he successfully deceives the other person and then feels contemptuous delight. Such feelings serve to maintain his narcissistic homeostasis as he demonstrates to himself, once again, that he is cleverer than his psychotherapist. The clinician will be left feeling angry and humiliated. Fear of assault or harm

Strasburger (1986) wrote that both reality-based and countertransference fears may co-exist when attempting to treat the psychopath. This particular reaction is an emotional defense in the clinician that is often signaled by autonomic arousal and visceral reactions, such as piloerection (“he made the hair stand up on my neck”), even in the absence of any actual violence or direct threat. Clinicians may

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also react autonomically to the predatory stare of the psychopath (Meloy, 1988), which is often a fear reaction to the absence of emotion in his eyes. Although the visual communication of emotion is a quotidian experience for most individuals, it appears to be absent in psychopathy, and may eventually be measured in the laboratory. Meloy and Meloy (2002) found that over three-quarters of a large sample of professionals described such autonomic reactions when in the presence of a psychopathic subject, most commonly a dermatological event or somasthetic feeling (“he made my skin crawl”). Such reactions may portend real danger and should never be ignored. Denial and deception

Denial is most often manifest in clinicians through their counterphobic responses to real danger. It is a common defense against anxiety generated by violent patients, and has been documented in those who witness mass murderers preparing for their acts, yet do nothing (Meloy et al., 2004). Sometimes clinicians will not believe that a patient has a criminal history despite the presence of a “rap sheet” and extensive documentation to the contrary. Clinicians will be heard referring to their patient as having “allegedly” committed a crime despite the fact that he has been tried and convicted by a jury. Case C Patient C was a psychopath and sexual sadist who was committed to a forensic hospital for the torture, rape and murder of several stranger females. During a quality assurance peer review of the patient’s chart, it was noted that the diagnosis of “sexual sadism” had been removed from his Axis I DSM-IV-TR formulation. When the treating psychiatrist was asked about this omission, he said, “oh, we dropped it since he hasn’t done anything sexually sadistic since he’s been here at the hospital.”

Deception of the psychopathic patient is most often done by the clinician when she is frightened of him and wishes to avoid his rage if she tells him the truth. It may also suggest superego problems, passive-aggressive behavior, or identification with the patient’s deceptive skills. Rigorous honesty without self-disclosure is a crucial treatment parameter with such patients. Helplessness and guilt

Clinicians beginning their careers may feel particularly helpless and guilty when an antisocial or psychopathic patient does not change despite their earnest efforts. It is difficult to accept the immutability of certain personality traits, especially when viewed through the prism of a treatment philosophy that endorses the basic goodness of human nature. Psychopaths challenge our desire to order and idealize the human experience. Sometimes such feelings originate in the clinician’s narcissistic belief that they have an omnipotent ability to heal others, what Reich (1951)

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referred to as the “Midas touch syndrome.” Psychopaths will exploit this narcissistic vulnerability by imitating back to the psychotherapist behaviors that confirm what he admires the most: his ability to heal the patient, and perhaps unconsciously defeat the therapists who had previously failed to help the patient. Devaluation and the loss of professional identity

If therapeutic competency is only measured through genuine change in the patient, psychopathy will be a source of continuous professional disappointment and narcissistic wounding. In institutional settings where contact with such patients is prolonged and controlled, clinicians will often report symptoms of depression and “burnout” due to their treatment failures and marginal positions of power and authority when compared to the staff responsible for security. Despite the adept management of the psychopath’s contempt, it is difficult not to feel despicable and devalued because of the primitive, preverbal nature of the patient’s defenses, often behaviorally manifest through belittling and aggressive gestures. Case D Subject D was the eighth individual to enter the young female psychologist’s office on her first day of work at a maximum security prison. She felt proud and confident of her skills, establishing rapport with the inmates and keeping her professional boundaries quite clear and forthright. When subject D sat down, he ignored her questions, and began talking about how she smelled. He speculated on the nature of her perfume, looked her over, and made suggestions for improving her smell and her appearance in the custody setting so as not to sexually provoke other inmates. She felt devalued and controlled, her lips and hands began to tremble, and she could not stop the tears welling up in her eyes. She abruptly ended the interview.

Hatred and the wish to destroy

Psychopathic patients despise goodness itself, and often work hard to damage the goodness they perceive in others to manage their envious feelings. Paradoxically, a psychotherapist who is devoted to being very competent and responsible with such patients will often stimulate the most envy in them. Some clinicians will identify with the psychopathic patient’s hatred and aggression to ameliorate his impact upon themselves (Gabbard, 1996). If not acted upon, such feelings in the clinician can be a source for understanding the psychopathic individual’s intensity of aggression and the biogenic or sociogenic roots of such impulses. It is not uncommon for psychotherapists or psychoanalysts working with such patients to have spontaneous homicidal fantasies prior to an awareness of the affective components of their aggression toward such patients. Searles (1979) explored the clinical awareness of a wish to kill one’s patient.

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Assumption of psychological complexity

The most subtle countertransference reaction to psychopathy is the clinician’s belief that the patient has the internal structure and developmental maturity of a neurotically organized individual, and it only has to be discovered in treatment. Severely psychopathic individuals are organized at a borderline level of personality at best, and they do not have the affective modulation, whole object relations, and tripartite structure that is evident in more treatable individuals (Gacono and Meloy, 1994; Kernberg, 1984; Meloy, 1988). This misapprehension is particularly common when evaluating a psychopathic patient who has a substantially above-average IQ and no other Axis I diagnosis. Some clinicians still adhere to the mistaken beliefs that all psychopathic patients have low self esteem, developmentally mature affects that are defended against (rather than non-existent), and a capacity for empathy and concern for others. There is abundant clinical and laboratory evidence that such is not the case (Hare, 2003). Fascination and sexual attraction

We would add another countertransference reaction that heretofore has not been discussed: fascination and sexual attraction. Some clinicians are strongly drawn to such patients, and provide for the psychopath an idealizing countertransference that he can regale with stories of his prowess and exploits. Young mental health professionals, especially women, will often be enamored with criminal forensic work for the sensation-seeking it delivers and the unconscious identifications with psychopathy which it invites. What is forbidden is often what is most desired. If clinicians come to understand the fantasized extremes of their own aggression and hedonistic desires, this fascination will often devolve into boredom, and then the clinical task becomes maintaining interest in a patient who offers little hope for change.

When treatment is undertaken In a perfect world, psychopathic individuals would be easily identified, not referred for mental health treatment, and all energies would focus on the safety of the unfortunate individuals living with or near them. Such is not the case. In both public and private treatment settings, prisons, jails, and outpatient practices, individuals with various degrees of psychopathy will present for treatment, and sometimes the clinician has no choice but to evaluate and attempt to treat them. There are a number of comprehensive chapters and books on treatment recommendations for antisocial-personality-disordered and psychopathic individuals (Ashford et al., 2001; Meloy, 2007; Wong and Hare, 2005) available to the reader.

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We emphasize, instead, six parameters of mental health treatment for such patients, regardless of the specific treatment methods applied in the clinical work. 1. The initial diagnostic evaluation must be comprehensive, and include interview, testing, and historical data independent of the patient’s self-report. The purpose of a careful diagnosis is to determine the severity of psychopathy – one of the Hare (2003) instruments is most useful – and individual differences within the patient that will aggravate or mitigate his psychopathic traits, which should be viewed as immutable. The clinical interview should assess the patient’s capacity to form attachments, the presence or absence of anxiety, and the severity of his superego disturbance, such as his history of deception. The more severe the psychopathy, the more apparent will be the patient’s chronic emotional detachment, fearlessness, and absence of any internalized values (Kernberg, 1984; Meloy, 1988). 2. Any treatable Axis I conditions, such as depression, anxiety, or substance abuse/dependence, should be identified and targeted for treatment. Substance abuse is the only Axis I disorder that appears to be comorbid with psychopathy (Hare, 2003), and other traditionally neurotic conditions, such as depression and anxiety, contraindicate a severe psychopathic disturbance, if they are genuine. The mendacity and malingering potential of the psychopathic patient should never be minimized, and psychological tests that are highly face valid – transparently communicating to the patient what is being measured – are often very useful to establish the genuineness of such neurotic conditions: psychopaths will typically endorse many more items than the truly anxious or depressed patient would on such measures. Some Axis I conditions, however, present a conundrum for the treating professional. For example, the paranoid schizophrenic who is also a severe psychopath is an exceedingly difficult challenge for the psychiatrist in a forensic hospital. If he or she successfully treats the Axis I condition, he or she will likely be faced with a better organized psychopath now living in the hospital. Is it medically ethical to treat such a patient subclinically to maintain a certain level of disorganization which increases the safety of other patients? Can the physician use the psychosis of the patient as a way to reduce his propensity for predatory violence? Such questions need careful consideration and are not easily answered. 3. Situational and environmental factors may aggravate the overt antisocial behaviors and need to be considered. These would normally be delineated on Axis IV of DSM-IV-TR. Careful consideration should be given to the use of alcohol or stimulants on the part of the patient to self-medicate against stressors or to simply sensation-seek in the face of a cortex that is chronically cortically underaroused (Raine, 1993). Other environmental stressors may be a product of his law breaking, and a rational discussion of his losses, such as freedom,

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family, or friends, may provide some motivation for change. If the psychopath can be persuaded that his life strategies have not paid dividends, perhaps he can utilize his strengths in a prosocial manner. 4. Legal problems and legal entanglements will likely be present, even if denied by the patient. In an outpatient forensic context, the mental health clinician may utilize law enforcement personnel (such as correctional officers, parole agents, and probation officers) and intermittent polygraph examinations to build a “containment team” inside which the psychopathic patient exists. Violations of the treatment contract or conditions of parole should be met by some loss of tangible privilege, such as the ability to travel freely, or by additional restrictions, such as increased contact with the treatment provider or the supervising officer. In private practice settings, the psychopathic patient’s mendacity should be contained through the unusual request for permission from the patient to discuss his case with collaterals (family members, spouse, etc.) when deemed necessary by the clinician. This provides a means of truth verification, which should never be assumed if psychopathy is present in the case. Clinicians who approach treatment from the position of intersubjectivity and solely depend upon the credibility and hope of the patient to guide the work are creating a wild, if not surreal, analysis that may be both emotionally and physically dangerous. 5. Careful attention should be paid to all countertransference reactions (Table 11.2) because they provide important insights into the inner world of the patient with a psychopathic disturbance. They also will inoculate the clinician against manipulation by the patient, and frustrate his sadomasochistic goal to dominate his objects. 6. Treatment should only be undertaken if it is safe and effective for the clinician and the patient. Psychotherapists who do not measure the severity of the patient’s psychopathy against their ability to remain safe – for example, attempting to treat a severely psychopathic individual in any voluntary outpatient setting – are placing themselves and other professionals in close proximity at great risk. The more severe the psychopathy, the more risk management is paramount. Case E Patient E began treatment at a public outpatient clinic with a psychiatric social worker. During the course of treatment, he revealed that he had committed a murder when he was younger. The therapist was frightened and shocked, but after consulting with her colleagues, realized that she had no legal obligation to investigate or report the past murder; and in fact, could not do so without violating the patient’s confidentiality. She also clinically believed the patient was benefitting from the treatment. Several months passed and the work seemed to be progressing nicely. Then one day the patient came in for his weekly psychotherapy session, sat down, and said, “it’s happened again.”

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Events such as this are extraordinarily unusual, but emphasize the importance of recognizing that impulsive or planned criminal activity on the part of the patient, whether directed toward the clinician or others, may eliminate the fiduciary responsibility of the clinician toward the patient, and obligate reporting to law enforcement.2 The first author has consulted on a number of cases in which a mental health clinician, in the throes of denial and rationalization, believed he still had a therapeutic responsibility to his patient despite the fact that he was being repeatedly criminally victimized by the same patient. In the case of Patient E, the university-affiliated clinic handled it very poorly. They consulted with their legal counsel who recommended that the patient be transferred to another mental health provider as quickly as possible. Conclusions Psychopathy is an immutable trait in certain patients which should give pause to the wise clinician before treatment is undertaken. It can be reliably measured, and, depending upon its severity, will have a minimal or massive impact on treatment outcome. We have discussed the nature of the beast, diagnostic issues, expectable countertransference reactions, and parameters that will help manage risk when such patients present for mental health care. Clinicians bear the burden of responsibility when deciding to treat such patients, since the psychopath, true to his character, believes he bears no responsibility at all.

R EF EREN CES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn., text revision. Washington, DC: American Psychiatric Association. Ashford, J., Sales, B. and Reid, W. (eds.) (2001). Treating Adult and Juvenile Offenders with Special Needs. Washington, DC: American Psychological Association. Babiak, P. and Hare, R. D. (2006). Snakes in Suits: When Psychopaths go to Work. Los Angeles, CA: Regan Books. Bursten, B. (1973). The Manipulator. New Haven, CT: Yale University Press. Cahill, T. (1986). Buried Dreams. New York: Bantam Books. D’Silva, K., Duggan, C. and McCarthy, L. (2004). Does treatment really make psychopaths worse? A review of the evidence. J Pers Disord 18: 162–177. Gabbard, G. (1994). Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington, DC: American Psychiatric Press. Gabbard, G. (1996). Love and Hate in the Analytic Setting. Northvale, NJ: Aronson. Gacono, C. and Meloy, J. R. (1994). The Rorschach Assessment of Aggressive and Psychopathic Personalities. Hillsdale, NJ: Lawrence Erlbaum Association.

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J. Reid Meloy and James A. Reavis Gacono, C. and Meloy, R. (2002). Assessing antisocial and psychopathic personalities. In J. Butcher (ed.) Clinical Personality Assessment: Practical Approaches. New York: Oxford University Press, pp. 361–375. Gacono, C., Meloy, R., Speth, E. and Roske, A. (1997). Above the law: escapes from a maximum security forensic hospital and psychopathy. J Am Acad Psychiatry Law 25: 547–550. Greenacre, P. (1958). The impostor. Psychoanal Q 27: 359–382. Hare, R. (1981). Psychopathy and violence. In J. Hayes, T. Roberts and K. Solway (eds.) Violence and the Violent Individual. New York, NY: Spectrum. Hare, R. (2003). Hare Psychopathy Checklist-Revised (PCL-R), 2nd edition, technical manual. Toronto: Multihealth Systems. Hare, R., McPherson, L. and Forth, A. (1988). Male psychopaths and their criminal careers. J Consult Clin Psychol 56: 710–714. Hare, R., Clark, D., Grann, M. and Thornton, D. (2000). Psychopathy and the predictive validity of the PCL-R: an international perspective. Behav Sci Law 18: 623–645. Harris, G., Skilling, T. and Rice, M. (2001). The construct of psychopathy. In M. Tonry and N. Morris (eds.) Crime and Justice: An Annual Review of Research. Chicago, IL: University of Chicago Press, pp. 197–264. Hart, S., Cox, D. and Hare, R. (1995). The Hare PCL:SV Psychopathy Checklist: Screening Version. Toronto: Multihealth Systems. Kernberg, O. (1984). Severe Personality Disorders. New Haven, CT: Yale University Press. Kessler, R., McGonagle, K., Zhao, S. et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 51: 8–19. Kiehl, K., Smith, A., Hare, R. et al. (2001). Limbic abnormalities in affective processing by criminal psychopaths as revealed by functional magnetic resonance imaging. Biol Psychiatry 50: 677– 684. Levenston, G., Patrick, C., Bradley, M. and Lang, P. (2000). The psychopath as observer: emotion and attention in picture processing. J Abn Psychology 109: 373–385. Lion, J. (1978). Outpatient treatment of psychopaths. In W. Reid (ed.) The Psychopath: A Comprehensive Study of Antisocial Disorders and Behaviors. New York: Bruner/Mazel, pp. 286–300. McGinniss, J. (1983). Fatal Vision. New York: Putnam Publishing Group. Meloy, J. R. (1988). The Psychopathic Mind: Origins, Dynamics, and Treatment. Northvale, NJ: Aronson. Meloy, J. R. (2001). The Mark of Cain. Hillsdale, NJ: The Analytic Press. Meloy, J. R. (2007). Antisocial personality disorder. In G. Gabbard (ed.), Treatments of Psychiatric Disorders, 4th Edition. Washington, DC: American Psychiatric Press. Meloy, J. R. and Meloy, M. J. (2002). Autonomic arousal in the presence of psychopathy: a survey of mental health and criminal justice professionals. J Threat Assessment 2: 21–33. Meloy, J. R., Hempel, A., Gray, T., Mohandie, K., Shiva, A. and Richards, T. (2004). A comparative analysis of North American adolescent and adult mass murderers. Behav Sci Law 22: 291–309. Monahan, J., Steadman, H. and Silver, E. (2001). Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. Oxford: Oxford University Press. Racker, H. (1968). Transference and Countertransference. New York: International Universities Press.

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Dangerous cases: when treatment is not an option Raine, A. (1993). The Psychopathology of Crime. San Diego, CA: Academic Press. Raine, A., Lencz, T. and Mednick, S. (1995). Schizotypal Personality. Cambridge: Cambridge University Press. Reavis, J. (1998). Individualistic-collectivistic cultures and psychopathy. Unpublished doctoral dissertation, United States International University, San Diego (1998). Reich, A. (1951). On countertransference. Int J Psychoanal 32: 25–31. Rice, M., Harris, G. and Cormier, C. (1992). Evaluation of a maximum security therapeutic community for psychopaths and other mentally disordered offenders. Law Human Behav 15: 625–637. Rule, A. (1980). The Stranger Beside Me. New York: W. W. Norton. Searles, H. (1979). Countertransference and Related Subjects. New York: International Universities Press. Seto, M. and Barbaree, H. (1999). Psychopathy, treatment behavior, and sex offender recidivism. J Interpersonal Violence 14: 1235–1248. Skeem, J., Monahan, J. and Mulvey, E. (2002). Psychopathy, treatment involvement, and subsequent violence among civil psychiatric patients. Law Human Behav 26: 577–603. Stewart, J. B. (1999). Blind Eye. New York: Simon and Schuster. Strasburger, L. (1986). Treatment of antisocial syndromes: the therapist’s feelings. In W. Reid, D. Dorr, J. Walker et al. (eds.) Unmasking the Psychopath. New York: W. W. Norton, pp. 191–207. Symington, N. (1980). The response aroused by the psychopath. Int Rev Psychoanal 7: 291–298. Vise, D. (2002). The Bureau and the Mole. New York: Atlantic Monthly Press. Weiner, I. (1998). Principles of Rorschach Interpretation. Mahwah, NJ: Lawrence Erlbaum Associates. Williamson, S., Hare, R. and Wong, S. (1987). Violence: criminal psychopaths and their victims. Can J Behav Sci 19: 454–462. Wong, S. and Hare, R. (2005). Guidelines for a Psychopathy Treatment Program. Toronto: Multihealth Systems Inc.

NO TES 1. PsycInfo search conducted by the first author, 1994–2004. 2. Statutes and case law concerning third party warnings and protections for violence risk vary from jurisdiction to jurisdiction. Clinicians should be thoroughly familiar with the applicable law in the geographical area where they practice.

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Stalking of therapists Paul E. Mullen and Rosemary Purcell

Introduction Being stalked is a relatively common experience in today’s world, with lifetime rates ranging between 10% and 25% depending on the definitions employed (e.g., Budd and Mattinson, 2000; Purcell et al., 2002; Tjaden and Thoennes, 1998). Mental health professionals, in addition to sharing the risks of the rest of the community, have a substantial additional probability of being stalked by their patients and clients (Galeazzi et al., 2005; Purcell et al., 2005). Episodes of stalking fall into two broad types: brief intense episodes of harassment typically only lasting a few days and perpetrated predominantly by strangers, and extended periods of stalking usually lasting for months, or even years, and most frequently involving pursuit predominantly by an ex-partner or acquaintance (Purcell et al., 2004). The stalking of mental health professionals by their patients unfortunately usually falls into the second pattern, which is more extended, and far more socially and psychologically damaging. The heightened vulnerability of the mental health professional derives from both the nature of some of those they seek to treat and the nature of the therapeutic relationship itself. Falling victim to stalking by a patient or a client is not usually the product of therapeutic ineptitude but is a risk inherent in almost all forms of mental health treatment. You may be able to reduce the risks of being stalked, and you can certainly learn to reduce the damage you suffer and the patient-turnedstalker suffers, but the only way for a therapist to guarantee they will never be stalked is to avoid seeing patients. In the wider community two of the commonest types of stalking to which people fall victim are persistent pursuit by rejected ex-intimates who will not accept the relationship is at an end, and brief but often intense episodes of harassment from strangers, most commonly seeking a sexual encounter or impulsively expressing  C Cambridge University Press 2007

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anger at an actual or supposed slight (Mullen et al., 1999). In the therapeutic context, stalking most frequently emerges from either a misplaced desire on the stalker’s part to establish an intimate relationship, or an ongoing experience of resentment and anger for some actual, or supposed, injury or humiliation. Just occasionally the attempt to terminate a long-term therapeutic relationship may evoke feelings and behavior reminiscent of the rejected stalker encountered when sexual and intimate relationships break down. This chapter will examine the nature of stalking in the therapeutic relationship. A brief survey of what is known about the prevalence of the stalking of therapists will be provided before considering how to both reduce the risks of being stalked and best manage this behavior when it emerges. At the very outset it needs to be emphasized that being stalked by a patient is not the fault of the therapist. Too often in the past therapists who fell victim to stalking by patients had to bear the additional burden of implied or open criticisms from colleagues to the effect that, had they more adroitly managed the therapeutic encounter and the resultant transference, they would not now find themselves in this predicament. We have no sympathy with blaming the victim, even if it comes in the guise of technical advice or supervision. Being stalked is a risk inherent to the therapeutic process. We owe our colleagues support and help, if for no other reason than we do not know when it may be our turn to face pursuit by a vengeful or lustful patient. Stalking of therapists Stalking involves the repeated imposition of unwanted communications or contacts in a manner which creates fear. To which the following codicil can be added, to limit the scope for the oversensitive: and would create such fear in any reasonable person. The fear induced in the victim is central to most legal definitions where the interest is in defining a form of harm that can properly be prohibited by the criminal law or remedied by the civil (McAnaney et al., 1993). In practice, repeated and persistent unwanted intrusions whether or not they are experienced as fear-inducing, are a distressing problem for the victim and a potential warning of worse to come. You may experience the unwanted and oft-repeated phone calls, and the stream of inappropriately personal and intrusive emails as a nuisance rather than a threat, but for all purposes except the legal this is stalking. This is pertinent in the stalking of a therapist who may allow their knowledge about, and sympathy for, the patientturned-stalker to foster a false sense of security. Therapists when stalked are prone to assume a continuing ability to control and ameliorate the stalker’s behavior based on their previous experience of managing the individual’s emotionality and behavior. This confidence is usually misplaced.

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Stalking is a problem behavior which has its own logic and dynamic. This can involve a dramatic break with previous ways of reacting and patterns of conduct. Assumptions based on the knowledge acquired in the prior treatment situation may, or may not, continue to apply. The problem is there is no certainty about such extrapolations and a lot may well depend on not making the wrong call. Studies of the stalking of therapists Studies of the stalking of mental health professionals fall into three broad groups on the basis of the nature of the study sample: 1. Case studies and case series gathered opportunistically. 2. Convenience samples involving studies of specific groups such as all members of a particular mental health service. 3. Random samples of large populations of health professionals usually selected from professional registers. Each method of sampling at this stage in the development of stalking studies has interest but the random samples of defined populations are the most informative and generalizable. A good example of a case history is psychiatrist Doreen Orion’s (1997) account of her own experience of being stalked by a client. She provides not only a detailed case history of both stalker and therapist/victim, but also an excellent account of what worked and what didn’t in trying to combat and cope with the stalker. Lion and Herschler’s (1998) work provides a good example of a case series describing the stalking by patients of nine clinicians, including seven psychiatrists, a psychologist, and a plastic surgeon. The latter is an example of an area of medical practice with even more problems with stalking than mental health professionals: angry, disappointed and resentful dysmorphophobics can make very frightening pursuers. Examples of studies of convenience samples are provided by Sandberg et al. (2002) and Galeazzi et al. (2005). Sandberg and colleagues (2002) reported on stalking behaviors experienced by the staff of an inpatient psychiatric facility in the United States. They found 8% had experienced harassing pursuits by patients, and in 3% this was felt to have threatened their safety. Galeazzi and his group studied the experience of being stalked in the mental health services of the Italian city of Modena. They obtained the cooperation of 76% of the staff. They used a conservative definition of stalking which only included repeated (more than ten episodes) and persistent (lasting longer than 4 weeks) intrusions which created concern or fear. They found that of the 361 nurses, psychologists, and psychiatrists who responded, some 40 (11%) had been stalked by patients. Males were significantly more likely to be stalked. Though all professional groups were included amongst the victims, it was the psychologists and psychiatrists who suffered the more extended period

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of being stalked. The median length of time the victims were stalked was 42 weeks (range 4–780) with the commonest unwanted intrusions being approaches (75%), repeated telephone calls (65%), loitering near their place of work or home (58%) and sending letters (33%). Threats occurred in 23% of cases and 7% were assaulted, with one sustaining serious injuries. The stalkers of health professionals in the study of Galeazzi and colleagues (2005) tended to be single (67%), usually with a primary diagnosis of a psychotic disorder (45%) or a Cluster B personality disorder (33%). The emotional impact on victims was substantial. The commonest motivation reported was the seeking of an intimate relationship with the professional (45%), with 13% pursuing a campaign of harassment to revenge themselves for some perceived wrong. Only 3 stalkers (8%) appeared to be pursuing the professional because they had felt rejected by what they regarded as a premature termination of therapy. The first study employing a random sample was conducted by Gentile et al. (2002). They obtained their sample from the register of those members of the American Psychological Association working in mental health services. They reported a history of stalking in 30 (10%) of the respondents though they did not provide an explicit definition of what constituted stalking. The stalkers were more likely to be female (68%), without a current intimate relationship (30%), and to have a primary diagnosis of personality disorder (75%). Purcell and colleagues (2005) employed a random sample of 1750 registered psychologists from the State of Victoria, in Australia, of whom 70% responded. Using a definition of stalking which included ten or more intrusions persisting for longer than 2 weeks, they found a lifetime prevalence of 19.5% (162), with 8% of psychologists stalked within the previous year. The highest reported rates were among psychologists specializing in the areas of forensic and general clinical psychology, with the lowest rates in neuropsychologists and organizational psychologists. No differences were found between male and female practitioners. Interestingly, 12% of the stalking was perpetrated not by the patient but by one of their relatives. Stalkers were significantly more likely to be male, with a primary diagnosis of personality disorder (50%) being the most common, followed by psychosis (27%). Forty-two percent of psychologists believed the stalking was motivated by resentment, with 19% believed to be pursuing in the hope of establishing an intimate relationship. In over 20% the psychologist was mystified as to what was driving the stalking behaviors. The infatuated clients were more persistent (median 6 months stalking duration) than the resentful (median 2 months) though there was wide individual variation (2 weeks to 5 years). Telephone calls were the commonest method of harassment (65%) followed by unwanted approaches (58%). Of considerable concern was the frequency with which stalkers made vexatious complaints (31%), most commonly to the registration board. Equally unexpected was the high rate

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of threats (38%). Assaults were preceded by threats in 86% of cases, and of those threatened some 20% were subsequently assaulted. The assaults mostly involved slapping and punching, but three cases of attempted strangulation were reported and one psychologist sustained a broken arm. Third parties such as reception staff, co-workers and relatives were also targeted with both threats (17%) and assaults (6%). Property damage was reported by 13% of the victims, usually involving vandalizing their car, though window smashing, trashing the office, and in one case arson, also occurred. The stalking impacted on the victims’ psychological and social well-being. Over 70% changed aspects of their professional and personal lives, some even relocating their work practice (6%) or residence (4%). Absenteeism as a result of being stalked occurred in nearly 20% of cases and almost one in three victims seriously considered leaving the profession in response, a figure which increased to nearly 50% in those exposed to vexatious complaints. Pattern of stalking of health professionals The work of Purcell and colleagues (2005) provides the clearest picture so far of the stalking of health professionals. The annual rate they report is 8%, with lifetime risks of nearly 20%. This is higher than most previous studies but this is likely to reflect better ascertainment rather than any idiosyncrasies of the study population. As you would expect, those who stalk mental health professionals are far more likely to have serious mental disorders than the general run of stalkers, if for no other reason than they came from a mentally disordered population. The differences in diagnostics between the studies to date is probably just a reflection of the different patient populations seen by the professionals studied. The only feature that stands out is that, like stalkers in other contexts, they are preferentially drawn from the socially inept and isolated. The gender differences in stalkers and victims found in the general population studies are not replicated in these studies of health professionals. Health professionals are not more likely to be stalked by males (see Purcell et al., 2001), and being male confers no particular protection against the behavior. The risks of threats and assault are similar to those found in the general population studies though there is a suggestion of a greater likelihood of serious violence being perpetrated and of significant property damage occurring. The motivations driving the stalking of mental health professionals are more likely to involve intimacy seeking and resentment than the anger and loss associated with rejection which play such a large part in the extended episodes of stalking in the general community. The angry resentful stalker is a particular problem for the mental health professional. This resentment can be triggered by a variety of conflict situations from unwelcome confrontations over such matters as substance abuse,

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through to a refusal to support with reports or letters the patient’s wishes in regard to such matters as work claims, custody, or compensation. For the psychiatrist, both the prescribing and the refusing to prescribe particular medications can form the basis for the grievance that sets the stalking in motion. The studies to date on the stalking of mental health professionals have tended to focus on the physical and social impact rather than the psychological distress and damage produced. The avoiding of this obvious dimension probably reflects a presumed, or actual, reluctance on the part of our fellow professionals to reveal details about their own psychological and emotional problems. Clinical experience of seeing colleagues stalked by patients makes clear the extent of the distress occasioned by therapists’ responses to being stalked by patients. Victims have a tendency to blame themselves. Stalking victims are particularly prone to castigating themselves. In the general community stalking victims typically blame themselves for such matters as: not having managed the separation better; for ever becoming involved with such a person; for giving the wrong messages; for their not coping more effectively; for being there; for not being there; for the way they reacted or didn’t react; and so on. The tendency to look at themselves and their behavior for an explanation of the stalking behavior of their tormentor is, as you would expect, even more prevalent among mental health professionals. The predilection for self-blame can be fostered by the attitudes of colleagues, who, presumably with the best of intentions, provide advice on how the victim might have better managed the situations. The impact of complaints by the stalker to professional boards, health ombudsmen and other agencies of accountability can be devastating. The complaints management processes employed by such organizations include an approach which initially takes complaints at face value and demands of the professional a “please explain” response. This reflects a routine institutional response untouched by the personal, which is understandable from the mandate of such organizations. It tends, however, to be experienced by the professional being complained about as anything but routine and rather as personal, implicitly critical, and as endowing the vexatious complaint with an unjustified status and probity. This usually evokes distress, but potentially worse still indignation, and a sense of being persecuted not by the stalker, but by the agency of accountability. These responses can cloud the professionals’ judgement about how best to manage their response. Angry, affronted responses are counterproductive, if for no other reason than that is how practitioners against whom entirely justified complaints have been laid typically respond. Conversely a misplaced mea culpa is definitely best avoided. In our experience the latter response is surprisingly common from practitioners who are victims of vexatious complaints from stalkers. To accept personal responsibility for events which were outside of your control, or to give credence to malicious interpretations of

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mundane or well-intentioned actions is in error. Some resentful stalkers will focus their complaints where therapists experience themselves most vulnerable, with that unnerving capacity found among some patients to discern the therapist’s own particular weaknesses and sensitivities. This can intensify the therapist’s pre-existing tendencies to self-doubt and even lead them into accepting the malevolent interpretations placed on their words and actions by the resentful patient. That there is often a kernel of truth in the stalker’s complaints does not mean the construction of accusations and imprecations with which they have invested that small truth should be treated with anything but the contempt it deserves. When facing malicious complaints the professional’s first and only responsibility is to their professional integrity and reputation. The time for understanding is past, the generosity of looking on both sides of the question is no longer appropriate; it is now a matter of surviving with as little damage as possible. Stalking and the therapeutic encounter Focused attention and concern is almost universal in therapy and, for many of our patients the only prior experience of such attention and concern will have been from mothers and lovers, and then for some only briefly and conditionally. Equally common in the therapy is the appearance of sympathy as in empathy and unconditional acceptance, if not of the patient’s behavior, at least of them as a person. Some therapists cultivate an interpersonal style which could cruelly, but accurately, be described as seductive. Given such a context it is not surprising that the therapeutic relationship can and does invoke in many patients a sense of intimacy with the therapist which may be experienced for some in terms of love and affection. Equally the therapeutic endeavor may produce not just disappointment when the implicit promises are not honored, or not honored quickly enough, but a sense of rejection and even humiliation. The emergence both of feelings of affection and of betrayal in the therapeutic relationship cannot be reduced just to transference phenomena, though they may be colored by such processes. The attention, concern, and implicit commitment to and for the patient in the therapeutic engagement are usually real aspects of the here and now. As is the raising of over-hopeful expectations and their disappointment. For the patient, the therapeutic engagement often evokes past experiences and even a reliving at some level of past relationships. Such transference is more marked in therapeutic encounters that are relatively unstructured, or structured in such a manner as to facilitate the patient’s freedom to determine the content of sessions. Such transference phenomena do not, however, entirely explain the emergence in therapy of love and hate, or their attenuated shadows, lust and resentment. This is important because however skilled a therapist is at recognizing and managing those

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transferred emotions, there remains a dilemma for the patient in the real feelings evoked in this concrete situation of the therapy. Training may assist in managing such conflicts and dissonance but in part they reflect the patient’s reactions to a real situation, and those reactions will be determined in no small part by the characteristics of the patient. Most patients, most of the time, can separate the therapeutic relationship from the relationships of everyday life. They can keep fantasy and reality separate. They accept, or at some level understand, the differences between professional concern and maternal love, between attention and the erotic, between the struggle toward small gains and the capacity to magically transform, between misunderstanding and persecution – most patients, most of the time, not all patients all of the time. Even among those who lose their grip on the restricted nature of the therapeutic relationship, most will articulate their over-hopeful or unduly suspicious attitudes in a form which allows them to be gently confronted or corrected within the therapeutic exchanges. Failures to recognize or face up to these issues may well disrupt treatment and create more problems than necessary, but it is not in and of itself likely to produce stalking. It is not stalking but embarrassment, distress, misunderstanding and lost therapeutic opportunities which are the usual price of ignoring the emotions evoked in the therapeutic encounter, both by transference and the actual interactions and exchanges. Stalking emerges, in our experience, on the basis of a vulnerability in the patient which may only become manifest with the stalking. A vulnerability which may be triggered by a wide range of therapist actions, and reactions most of which would have been helpful or innocuous in the vast majority of patients. There is a temptation to look for technical and professional failings in the therapists to explain the emergence of stalking, particularly when the therapist employs approaches to treatment about which you are personally skeptical. In two stalkers we assessed, our initial formulation placed a considerable amount of the responsibility on the therapist’s behavior. In one, the therapist had abruptly terminated therapy after some years having apparently made no alternative arrangements, and in response to what appeared a relatively mild tantrum directed at the practice receptionist. In the second, the therapist appeared to have tolerated, or even encouraged, contact outside of the therapy involving interactions more appropriate to friendship which might have encouraged expectations of greater intimacy (though there was no sexual impropriety). The management of these stalkers was influenced by the negative view we embraced of the therapists. In both these cases it became clear subsequently that we had misjudged the therapists as a result of too ready a willingness to accept the stalker’s account of events. In these two cases, both patients went on to stalk subsequent therapists, having received no effective treatment from our service and possibly even inadvertent encouragement. Those

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who deal with stalkers soon learn to be wary of the rationalizations, denials, and subtle, and not so subtle, rewriting of history. That wariness should not be allowed to diminish when the victims are fellow professionals, even if they are wedded to therapeutic orientations we distrust. Can you predict which patient will stalk their therapist? What then are the warning signs that a patient, or potential patient, may finish up stalking their therapist? The difficulty is not in answering that question, but in answering it in a way which doesn’t involve either stigmatizing a wide range of patients, drawn from the most disabled and needy of those who seek our help, or creating unnecessary alarm about the lonely and socially incompetent whose lives are bereft of intimacy, but who nevertheless still crave closeness and love. Sensitivity, self-reference, and self-absorption combined with loneliness, be they associated with psychosis or not, are a mix found in many who stalk in search of intimacy. That patient profile sadly is not uncommon but very few of those who conform to such a description will stalk, however attached in fantasy they may become to therapists. Suspicious, litigious individuals, ambivalent or rejecting of therapy, who combine grandiose entitlement with a corrosive ressentiment, are a risk for resentful stalking. Here again however, the attributes are far from rare and though nearly all such patients are likely to be “difficult,” few will resort to actual stalking and, if they do, their therapist is not the most likely target. What of those who have previously stalked therapists, are they not at high risk of repeating their behavior? Again the answer is a bit of yes and a lot of no. Intimacyseeking stalkers have usually made a commitment once and for all, and even when they can be induced to give up stalking they usually retain a nostalgic attachment to the lost “love.” Such people are unlikely to move on to a new target except when the pathology of love is secondary to a schizophrenic disorder. Those with a schizophrenic syndrome, particularly of the disorganized variety, may shift their unwanted attentions to a new therapist, sometimes insisting that the new is the old in disguise or reincarnated. Resentful stalkers are less predictable, particularly if they have stalked a health professional more as a representative of a corrupt system than out of a specific and personal animus. In such cases, extreme care has to be taken not to allow conflict to re-emerge in the new therapeutic context. In our service we attempt to manage such individuals by using co-therapists or even by involving several principle therapists to avoid the focusing of animosity on a single individual. Our experience over the last decade of assessing and managing over 200 stalkers is that they rarely harass or stalk our staff. However, of the handful who have become nuisances, or have engaged in more prolonged stalking, nearly all came from the subpopulation referred because they were stalking mental health

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professionals; and many had histories of serial stalking having targeted more than one victim. Avoiding and surviving stalking Avoid being stalked? You cannot. At least not entirely. Not that is if your practice brings you in contact with the lonely, distressed, incompetent, suspicious or angry. Stalking is a risk inherent in the therapeutic engagement. The question is how to minimize the damage from the stalking situation. Path´e’s (2002) book Surviving Stalking provides the best general guide and can be recommended to all therapists as a source for advising stalking victims and personal survival in the stalking situation. This paper will just highlight areas of specific relevance to the mental health professional. Early recognition

In our experience many therapists are slow to even consider that one of their patients may be stalking them. Even when they allow themselves to suspect this is happening, many retreat into rationalizations and denial. “He’s just going through a bad patch and is needing more reassurance at the moment.” “It’s odd, I never realized before that we went to the same gym and supermarket.” “I should have managed the termination with a little more sensitivity.” “She’s understandably upset about the report I sent to the university.” “I suppose it’s a mistake anyone could have made in the circumstances.” Not only sympathy and the struggle to understand obscure the obvious from the therapist about to become victim; narcissism also plays its role. One physician contacted us, “at the insistence of his wife” about a female patient who over several months had been sending him “silly love notes” and “flowers would you believe.” The patient was also loitering around the doctor’s home and attempting to strike up conversations with his two children. When advised as the first step he should immediately transfer her care to a colleague he replied, “I couldn’t do that. She has a very complex and unusual medical problem and nobody else is likely to be able to manage it properly.” He explained her behavior was just something he as a physician, “had to put up with.” Fortunately his wife eventually persuaded him differently. Informing

On suspecting a patient may be stalking you, the initial response should be to share those concerns with colleagues. This performs two functions. The first is obtaining what will hopefully be a set of more detached responses to what has been occurring, which may be reassuring but more usually will reinforce the suspicions that stalking is occurring. The second is to inform those you work with that this is occurring

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to facilitate their providing practical, professional, and personal support. Stalked therapists often keep their suspicions, or even the fact, that they are being stalked to themselves from misplaced embarrassment, or an even more misplaced confidence in their capacities for managing the situation. Those working in mental health teams or in group practices will usually have little problem in enlisting the support of colleagues in these situations. Single-handed or otherwise isolated practitioners are in a far more vulnerable position which makes the sharing of the information with colleagues all the more important. If the lone practitioner does not have a formal or informal peer support group they should discuss the situation with a colleague in whom they have confidence. The second person to share the concerns with is the patient-turned-stalker. This should only occur following consultation with colleagues and deciding on a course of action. The interview with the stalker is not the context in which to decide on how you should act, it is the time to share your decisions with the stalker. If the initial intrusions were of a nature to raise concerns about your safety it is perfectly appropriate to see the patient in the company of a colleague, ideally the one who will be taking over the patient’s management. Usually the best course of action is to: 1. Inform the patient their intrusions have created concern and distress for you. 2. Inform them that as a result their care is to be transferred to a colleague. 3. Make clear there will be no further involvement by you in their care and no further contact or communications. Make clear attempts to continue to intrude with unwanted contacts or communications will potentially result in their being criminally prosecuted. 4. Express, if appropriate, regret it has ended like this, etc. Do not debate the details. Do not apologize. Keep the “no future contact” unambiguous. Finally, if stalked, make sure you let those you live with know this is happening. Partners, close friends and those you live with need to know what is happening because: 1. They may be targeted by the stalker. 2. They can’t help you if they don’t know. 3. They need to know why you may be more anxious and avoidant than usual. The wish not to worry those you are close to can inhibit sharing the information that you are being stalked. This is an error that can occasionally put those left in ignorance in danger. In one of our cases, a doctor who did not inform his partner about a patient who was stalking him learnt subsequently that this man had made contact with her at the university and was in the process of enrolling in one of her seminars. In another case, the partner first learned of the stalking, which had been going on for over 6 months, when their home was set on fire.

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Keeping records

Whatever the usual attitude of the clinician to keeping detailed written notes, when any suspicion of stalking is raised good notes made contemporaneously become mandatory. Record all unwanted contacts. Record all actions and discussions. Record in detail the current situation in therapy. Record one’s management plan for the stalking and the transfer of care. Given the high rates found of complaints to registration and other regulatory boards by stalker-patients about their victims, prudence dictates detailed notes. Personally we would also keep copies of the notes in a secure place as we have encountered a number of cases where the patient-turned-stalker has stolen their records. Finally, record in the knowledge that what you write may become public and may eventually be read by the stalker. So keep the notes factual, straightforward, and professionally sympathetic. There are two separate, though often linked, areas about which records require to be kept: records of the therapeutic situation and records of the stalking activities. To document the stalking the following is recommended: 1. Keep copies of all unwanted communications and enclosures. The temptation to transfer them rapidly to the waste bin should be resisted. 2. Record unwanted contacts. A diary is useful if the stalking has escalated to the point where such contacts are becoming frequent. Ideally when you record an episode of following, loitering outside your rooms or approaches, try to have witnesses sign and date that they saw the event. 3. Retain records of unwanted phone calls – the use of answering machines enables tapes of the calls, even hang-up calls, to be retained with automatic timing included. Legal remedies

The law usually offers civil and criminal responses to being stalked. The civil usually involves the victim obtaining a court order which instructs the stalker not to communicate, contact, or approach within stated limits. The victim obtaining such orders usually has to engage a legal representative and this can, if opposed, be a costly undertaking. Their efficacy in constraining the behavior of stalkers is in our experience variable. We have found that they are usually least effective against those stalkers whose persistence and intimidatory behaviors cause the greatest concern. Criminal prosecution of those indulging in stalking behaviors is now possible in most jurisdictions. In our view it is the appropriate response to stalking behaviors which continue after transfer of care, or which are creating significant distress. Police are not always responsive to complaints about being stalked. Their willingness to act is greatly increased if you can bring with you the letters, emails, phone records and tapes, diaries, etc., which document and bear witness to the stalking. Going to the police accompanied by a colleague who has either witnessed or been privy to

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the harassment also increases the likelihood of the police assisting. The clearer the evidence, and the less work the police will have to do, the more likely they are to act. How they act is to a large extent their choice. Some forces start by interviewing and issuing a warning, others proceed immediately to laying charges. If given a choice the former is usually preferable as an initial response as long as you are confident of a more rigorous response if that fails to curb the behavior. Looking after yourself

Cobblers’ children have traditionally been the worst shod, and therapists certainly tend to be the least well cared for from a mental health perspective. Though some colleagues will tolerate years of therapy in the name of training, they will not allow themselves even a single consultation in the name of their own mental health. Selfmedication, self-therapy, and other forms of silliness are indulged in by mental health professionals who would be horrified if their patients tried the same tricks. The reluctance to seek appropriate help has various roots: pride, shame, and not least that of ignoring or redefining one’s own distress and disturbance. Being stalked is stressful. The evidence for its impact on the psychological wellbeing of victims is clear (Blaauw et al., 2002; Kamphuis and Emmelkamp, 2001; Path´e and Mullen, 1997). Mental health professionals who have suffered the experience of being stalked should as a priority seek advice, and, if necessary, treatment from a colleague experienced in this field. Stalking victims tend to develop a range of stress responses which can lead to avoidant behaviors which leave them increasingly isolated and socially disabled. The feeling of helplessness and futile anger can breed distrust and withdrawal even from intimates and friends, further compounding the psychological and social damage. Depression is an ever-present risk in these situations. Suicidal impulses are common and suicide, sadly, can occur as a result. Sharing the knowledge that you are being stalked with colleagues, friends, and intimates reduces the risk of some of these reactions, but does not remove the risk. In managing the psychological impact of stalking, individual therapy, pharmacotherapy, and victim support groups all have a place (Path´e et al., 2001). This is not the place to discuss the management of stalking victims. It is the place to remind colleagues that a training in mental health does not exempt them from stress reactions, affective disorders, and maladaptive responses. Obtain the professional help for yourself that you would urge on your patients in the same situation. Conclusions Stalking is becoming an increasingly common form of behavior in response to a range of today’s social and cultural stressors (Mullen et al., 2001). The stalking of

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mental health professionals is connected to these changes in modern society, which are driving the stalking epidemic. Therapists are peculiarly vulnerable because they are far more likely to come in close contact with the lonely, alienated, and angry of the world. Stalking is driven by social realities in combination with personality vulnerabilities in the stalker. These vulnerabilities are particularly likely to be expressed in the context of a therapeutic relationship, and are imminent in all such relationships. As therapists we cannot avoid the risk of being stalked. As mental health professionals we should be able to use the evidence base about this problem behavior to facilitate early recognition and optimum management of the stalker, and avert potential social and psychological damage to ourselves.

R EF EREN CES Blaauw, E., Winkel, F. W., Arsensman, E., Sheridan, L. and Freeve, A. (2002). The toll of stalking: the relationship between features of stalking and psychopathology of victims. J Interpers Violence 17: 50–63. Budd, T. and Mattinson, J. (2000). The Extent and Nature of Stalking: Findings from the 1998 British Crime Survey. London: Home Office Research, Development and Statistics Directorate. Galeazzi, G. M., Elkins, K. and Curci, P. (2005). The stalking of mental health professionals by patients. Psychiatr Serv 56: 137–138. Gentile, S. R., Asamen, J. K., Harmell, P. H. and Weathers, R. (2002). The stalking of psychologists by their clients. Prof Psych Res Pr 33: 490–494. Kamphuis, J. H. and Emmelkamp, P. M. G. (2001). Traumatic distress among support-seeking female victims of stalking. Am J Psychiatry 158: 795–798. Lion, J. R. and Herschler, J. A. (1998). The stalking of clinicians by their patients. In J. R. Meloy (ed.) The Psychology of Stalking: Clinical and Forensic Perspectives. San Diego, CA: Academic Press, pp. 165–173. McAnaney, K. G., Curliss, L. A. and Abeyla-Price, C. E. (1993). From imprudence to crime: anti-stalking laws. Notre Dame Law Rev 68: 819–909. Mullen, P. E., Path´e, M., Purcell, R. and Stuart, G. W. (1999). A study of stalkers. Am J Psychiatry 156: 1244–1249. Mullen, P. E., Path´e, M. and Purcell, R. (2001). Stalking: new constructions of human behaviour. Aust N Z J Psychiatry 35: 9–16. Orion, D. (1997). I Know You Really Love Me: A Psychiatrist’s Journal of Erotomania, Stalking, and Obsessive Love. New York: Macmillan. Path´e, M. (2002). Surviving Stalking. Cambridge: Cambridge University Press. Path´e, M. and Mullen, P. E. (1997). The impact of stalkers on their victims. Br J Psychiatry 170: 12–17. Path´e, M., Mullen, P. E. and Purcell, R. (2001). Management of victims of stalking. Adv Psychiatric Treat 7: 399–406.

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Paul E. Mullen and Rosemary Purcell Purcell, R., Path´e, M. and Mullen, P. E. (2001). A study of women who stalk. Am J Psychiatry 158: 2056–2060. Purcell, R., Path´e, M. and Mullen, P. E. (2002). The prevalence and nature of stalking in the Australian community. Aust N Z J Psychiatry 36: 114–120. Purcell, R., Path´e, M. and Mullen, P. E. (2004). Editorial: when do repeated intrusions become stalking? J Forens Psychiatry Psychol 15(4): 571–583. Purcell, R., Powell, M. B. and Mullen, P. E. (2005). Clients who stalk psychologists: prevalence, methods and motives. Prof Psychol Res Pr 36(5): 527–543. Sandberg, D. A., McNiel, D. E. and Binder, R. L. (2002). Stalking, threatening, and harassing behavior by psychiatric patients toward clinicians. J Am Acad Psychiatry Law 30: 221–229. Tjaden, P. and Thoennes, N. (1998). Stalking in America: Findings from the National Violence against Women Survey. Washington, DC: National Institute of Justice and Centers for Disease Control and Prevention.

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Common elements of effective treatments W. John Livesley

Treatments for personality disorder have increased substantially in recent years. The initial domination of the field by psychoanalytic therapies changed in 1990 with the publication of Cognitive Therapy by Beck, Freeman, and Associates. This publication was quickly followed by volumes on interpersonal (Benjamin, 1993) and dialectical behavioral therapies (Linehan, 1993). Subsequently, other cognitive approaches were developed (Layden et al., 1993; Young et al., 2003), Kernberg’s transference-based therapy was manualized (Clarkin et al., 1999), and additional psychoanalytically based treatments such as mentalization-based therapy (Bateman and Fonagy, 2004) were proposed. The growth in psychotherapeutic treatments has been accompanied by increasing interest in pharmacological interventions to both manage the symptomatic component of personality disorder and modulate the expression of important traits such as impulsivity, affective lability, and cognitive dysregulation (Soloff, 2000). The clinician now has a range of treatment options and treatment modalities to choose from. Unfortunately, however, the evidence needed to make an informed choice among these alternatives is limited. This need not be an insurmountable problem. Rather than opting for any one form of therapy, the clinician could adopt an eclectic and integrated approach using intervention strategies common to all effective therapies. If needed, these generic strategies can be supplemented with an array of specific interventions selected from different treatment models to treat problems not addressed by generic mechanisms. This is in effect what most experienced clinicians do. They use a combination of interventions that they have found effective and tailor these to the problems of individual patients. This chapter argues not only that this is a viable strategy, but also that an integrated approach is the most appropriate strategy given current evidence of treatment effectiveness and consideration of the scope and limitations of current therapies.

 C Cambridge University Press 2007

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Contemporary perspectives on the treatment of personality disorder The recent proliferation of treatments and associated theories is a positive development that should lay the foundation for a more systematic body of knowledge about personality disorder and more coherent treatment. However, the proliferation of treatments also indicates the relatively immaturity of the field and perhaps the limited efficacy of current therapies. Most fields of scientific endeavor pass through a stage when multiple general and largely speculative theories are offered as comprehensive accounts of the field. Such a proliferation of global theories occurred in the study of normal personality in the middle and latter parts of the last century. Perusal of any text of the time reveals chapters on each of the theories in vogue at that time, such as psychoanalytic theories, social psychological theories, trait theories, motivational models, humanistic theories, and so on (see for example Hall and Lindzey, 1957). Personality disorder seems to be in a similar phase. The field is diffuse and fragmentary. About a dozen therapies are currently available to treat the disorder or a specific variant, each offering a different but largely speculative explanation of the disorder and its etiology. Because these theories incorporate different perspectives, they tend to be considered alternative models and hence many clinicians think that their task is to select the most effective. For this reason, there is currently considerable interest in comparing the outcome of different treatments. There are reasons to question the merits of such a horse-race approach. First, most therapies address a limited range of problems and none is sufficiently comprehensive to address the range of psychopathology observed in typical cases. This range includes symptoms, situational problems, emotion and impulse dysregulation, maladaptive traits, maladaptive interpersonal patterns, and a poorly developed self or identity. Most models selectively target these domains. Thus a specific condition such as borderline personality disorder is variously considered a cognitive, interpersonal, or object relations problem or to be due to a specific deficit such as affect dysregulation or problems with “mentalizing.” Each model tends to spawn its own interventions, to varying degrees its own program of research, and its own set of supporters. As a result, knowledge remains fragmented. Most cases of borderline personality disorder show problems in all of these areas. Thus far from being alternative treatments, most therapies could profitably be considered to have complementary elements. Under these circumstances, it makes more sense to identify the essential features of current treatments and to take what works from the different approaches rather than arbitrarily select a single approach with limited scope (Livesley, 2003, 2007). Second, there is limited empirical support for all treatments. Few trials use the sample sizes needed for generalizable results and even therapies that claim support

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from randomized controlled trials offer little information on long-term outcome. This is essential to determine whether the short-term changes usually reported reflect treatment effects as opposed to the short-term instability that characterizes current diagnostic constructs – a surprising conclusion from longitudinal studies is the degree to which changes in diagnosis occur over comparatively short time periods (Skodal et al., 2005; Zanarini et al., 2005). Third, there is little evidence that any treatment is substantially better than the rest. Psychodynamic and cognitive treatments are effective (Paris, 2005; Piper and Joyce, 2001) and produce similar magnitudes of change (Leichsenring and Leibing, 2003). This suggests that change is primarily due to generic mechanisms rather than specific interventions that characterize each model (Livesley, 2003; Paris, 2005). Although this possibility is rarely discussed by the proponents of these models, it is consistent with the general literature on psychotherapy outcome: meta-analyses show that the different therapies produce similar results (Beutler, 1991; Luborsky et al., 1975). The implication is that different therapies share common elements that are associated with successful outcome (Norcross and Newman, 1992). Fourth, despite these similarities, there is also modest evidence that the effectiveness of interventions varies across domains of personality pathology (Piper and Joyce, 2001). Treatment seems to be most effective when specific behaviors are targeted using specific interventions. For example, symptoms such as parasuicidal and impulsive acts respond to behavioral and cognitive behavioral interventions (Davidson and Tyrer, 1996; Lieberman and Eckman, 1981; Linehan, 1993; Linehan et al., 1991; Perris, 1994). Symptoms of social anxiety respond to social skills training (Argyle et al., 1974; Marzillier et al., 1976). Although empirical evidence is lacking, rational considerations suggest that maladaptive cognitions will respond to cognitive therapy (Beck et al., 1990; Young and Lindemann, 1992), while the synthesis of more adaptive self structures and the integration of separate aspects of self-experience may also require interventions drawn from psychoanalytic and constructionist approaches. Given modest evidence of differential responsiveness, the heterogeneous origins of severe personality disorder, and the wide range of psychopathology involved, it is reasonable to conclude that rather than comparing treatments to determine which is the most effective, a better strategy would be to combine therapeutic mechanisms that are common across methods with an array of interventions from different treatment models to target specific problems based on what works. Although generic change mechanisms account for a substantial amount of outcome change, they are not the only factors common to current therapies for personality disorder. Effective treatments also share a structured approach that involves the establishment of an explicit therapeutic frame and treatment contract, and systematic procedures to maintain therapist and patient compliance. Besides these shared

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elements, most therapies also share conceptual and theoretical assumptions about the nature and origins of personality disorder that have a bearing on intervention strategies. The following sections consider these three themes. Common or generic factors The important conclusion of meta-analyses of psychotherapy outcome that generic influences account for substantially more change than specific interventions suggests that evidence-based therapy should maximize the effects of common factors (Livesley, 2001, 2003). Empirical research shows that generic mechanisms involve a relational and supportive component based on the therapeutic relationship and a technical component that promotes new learning experiences and opportunities to apply new skills (Lambert, 1992; Lambert and Bergen, 1994). Treatment is most effective when a competent therapist conveys trust, acceptance, and respect in the context of a collaborative relationship that provides a safe environment which supports attempts to behave in new ways (Beutler and Harwood, 2000). The important element here is the treatment alliance: multiple studies indicate that the quality of the alliance is a major predictor of outcome. A good alliance seems to be both a prerequisite for effective use of other interventions (Gaston, 1990; Horvath and Symonds, 1991) and an ameliorative factor independent of other treatment techniques (Strupp and Hadley, 1979; Weinberger, 1995). Several attempts have been made to delineate generic change mechanisms (Karasu, 1986; Lambert, 1986; Orlinsky and Howard, 1987; Prochaska, 1984; Prochaska and DiClemente, 1992; Weinberger, 1995; Winston and Muran, 1996). Although these formulations parse generic mechanisms differently, they agree on the importance of a supportive therapeutic relationship and instrumental interventions that increase self-knowledge, offer new experiences inside and outside treatment, and promote new behaviors. Generic factors in the treatment of personality disorder

An emphasis on generic mechanisms is especially pertinent to the treatment of personality disorder – generic interventions offer an effective way to manage and treat the maladaptive interpersonal patterns and dysfunctional self structures that characterize the disorder. Many of the problems encountered in treating these patients occur because self and interpersonal problems hinder the establishment of an effective working relationship and because maladaptive patterns and reactive emotions are often activated in ways that interfere with therapy. Generic interventions are inherently supportive and hence place less stress on the relationship than a more challenging interpretative stance (Horowitz and Marmor, 1985). At the same time, generic interventions offer effective ways to modulate core interpersonal and self

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pathology. This occurs because the main feature of an effective alliance is collaboration. Hence the steps taken to build a collaborative relationship automatically address core interpersonal problems. The relationship component of generic mechanisms can be operationalized and tailored to the treatment of personality disorder by organizing treatment around interventions to: (1) build a collaborative relationship; (2) maintain a consistent treatment process; (3) promote validation; and (4) build motivation and the commitment to change (Livesley, 2001, 2003). These strategies are designed to foster the alliance and create a treatment process that provides ongoing opportunities to modify core schemata. The emphasis on the collaboration needed to promote the treatment alliance also helps the patient to recognize and change problems in working cooperatively with others and modulate maladaptive schemata involving trust, intimacy, and cooperation. A consistent treatment process provides the stability needed for any intervention to be effective while also helping to modify beliefs about the inconsistency and unpredictability of relationships arising from adverse developmental experiences. The therapist’s efforts to maintain consistency also model the maintenance of interpersonal boundaries. At the same time, a consistent therapeutic process offers the patient a stable experience of the self in relationship with the therapist that can contribute to a more coherent self system. Validating interventions convey the support needed to build the alliance and begin to correct self-invalidating ways of thinking that hinder the formation of a coherent self structure. They facilitate change by enhancing the feelings of authenticity that are fundamental to self-understanding. Finally, efforts to build motivation create the commitment necessary for change while also helping to modify the beliefs of passivity and limited self-efficacy that contribute to low self-esteem and perpetuate maladaptive patterns.

Building and maintaining a collaborative relationship

Although an effective alliance is essential for successful psychotherapeutic treatment of any condition, the alliance has additional significance when treating severe personality disorder because multiple factors hinder alliance formation. Many patients lack the relationship skills required for collaborative work. Earlier adversity leads to caution about relationships and negative expectations about the availability of help and support. Feelings of envy, conflicted attitudes toward authority, and dependency conflicts also interfere with the process. Problems also arise due to maladaptive traits. Traits associated with emotional dysregulation, for example, contribute to emotionally charged and unstable relationships. Because of these factors, an essential element of most therapies is the priority given to building, maintaining, monitoring, and repairing the alliance (Beck, 1995; Beck et al., 1990,

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2003; Benjamin, 1993; Chessick, 1979; Cottraux and Blackburn, 2001; Meissner, 1984, 1991; Robins et al., 2001; Young et al., 2003). Two ideas are useful for this purpose: Luborsky’s (1984) two-component description of the alliance and Safran and Muran’s (2000) work on repairing ruptures to the alliance. Both methods seem to capture essential ingredients of both psychodynamic and cognitive therapies. On the basis of empirical analyses, Luborsky suggested that the alliance has a perceptual-attitudinal component wherein patients see their therapist as helpful and themselves as accepting help, and a relationship component wherein patient and therapist work cooperatively to help the patient. This suggests two broad strategies for building the alliance. The first involves building positive expectations of a successful outcome by helping patients to understand that their condition can be treated, enhancing the credibility of therapy and the therapist, and encouraging patients to accept help. These conditions are achieved by conveying optimism, communicating a realistic sense of hope about treatment outcome, conveying understanding and acceptance of the patient’s problems, supporting the patient’s treatment goals, recognizing and supporting areas of ability and competence, and recognizing any progress made in achieving treatment goals. The second strategy builds a cooperative and collaborative relationship by encouraging patients to engage with therapists in a collaborative search to understand their problems, by facilitating the patient–therapist bond, emphasizing the collaborative nature of treatment, and reminding the patient of positive experiences in therapy. Consistent use of these interventions is not only effective at building the alliance but it also helps to contain emotional distress and impulsivity and reduce the activation of more reactive behaviors that may threaten therapy. Steps taken to build the alliance begin during assessment and continue into discussions about the treatment contract. When assessing patients, therapists facilitate the alliance by asking questions that convey an understanding of the patient’s problems and sharing with the patient preliminary ideas about the nature of his or her difficulties. As assessment moves to a discussion of treatment options and the treatment agreement, further opportunities arise to enhance collaboration by working with the patient to define treatment goals. Ruptures to the alliance are best addressed immediately using Safran and Muran’s (2000) four-stage process. The first step is to notice changes in the alliance – what they refer to as “rupture markers” – such as changes in emotional state, decreased rapport, disagreement with the therapist, and so on. Next, the patient’s attention is drawn to the event and the reasons for the rupture are explored. Third, the patient describes his or her experience, which is validated by the therapist. If these steps are not effective, a fourth step is used which involves exploring how the patient avoids recognizing and discussing the rupture. This process offers valuable opportunities

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for the therapist to model openness and collaboration and to modify maladaptive schemata. Maintaining a consistent treatment process

Most therapies, especially psychodynamic treatments, emphasize the importance of consistency (see Waldinger, 1987; Waldinger and Gunderson, 1989). Patients with severe personality disorder tend to live chaotic lives and few have experienced stable relationships with significant others. Consistency provides the structure needed to contain emotional and behavioral lability and support other interventions. It also helps to modulate maladaptive interpersonal patterns by providing the experience of a predictable relationship. Consistency depends upon having established a clearly defined therapeutic frame and treatment contract, which provide a reference point for monitoring consistency. Maintenance of consistency is a challenge throughout treatment. Unstable self-states and associated emotions, distrust, and difficulty with cooperation drive recurrent attempts to alter the frame. Past relationship experiences can also lead patients to challenge the therapist’s resolve to maintain consistency. Maintenance of consistency requires skill in setting limits without damaging the alliance or modifying the supportive and validating therapeutic stance. This is best achieved by confronting attempts to change the frame immediately while also offering support and understanding. With most approaches this involves recognizing, and thereby validating, the reasons for the frame violation while also pointing out how the violation may have an adverse impact on therapy. This combination of gentle confrontation, reality testing, and support offers the most effective way to maintain a working relationship in the face of such challenges. An inconsistent treatment process suggests that the therapist is having difficulties due to such factors as unclear goals, poor treatment plan, or countertransference problems. Establishing a validating treatment process

The importance of recognizing and affirming the legitimacy of the patient’s experience is recognized by therapies as theoretically diverse as self psychology and Dialectical Behavior Therapy (DBT). Self psychology considers an empathic and validating stance to be the essential ingredient of the treatment of narcissism (Kohut, 1975). DBT makes extensive use of validation strategies to counter the effects of invalidating environments in childhood that are considered to play a crucial etiological role in the development of borderline personality disorder (Linehan, 1993). Validation has multiple functions. It contributes to the alliance by providing support and empathy and helps to contain and settle emotional distress and reactivity. With severe personality disorder, emphasis is placed on emotional regulation

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rather than emotional expression because most patients have difficulty regulating and controlling emotions and intense affects tend to be destabilizing at least during the early stages of therapy. Empathic acknowledgement of distress helps to reduce the tendency for feelings to escalate out of control when patients feel that their distress is not recognized or understood. Validation also counters self-invalidating ways of thinking. Invalidating environments exert a lasting influence on adaptive functioning when they give rise to a cognitive style that causes patients to question the authenticity of their feelings, interpretations of events, hopes, and aspirations. Most patients do not realize how they continually question and second-guess the genuineness and accuracy of their feelings and understanding of events. This undermines their sense of who they are and their ability to establish direction and purpose to their lives. As one patient commented: “How can I decide what I want to do with my life when I doubt everything about myself.” The therapist’s consistent acceptance of the patient’s experience as the first step in trying to understand it helps to counter earlier invalidation and this way of thinking. Validation by the therapist is often more an attitudinal stance and therapeutic style than a specific set of interventions. The approach encourages patients to take the time needed to describe their feelings and experiences and repeatedly affirms them. It also requires therapists to strive to make problematic experiences, responses, and situations understandable given the circumstances of the patient’s life (Linehan, 1993) – a process that is part of the general search for meaning that Yalom (1975) considered essential for therapeutic change. A search for understanding is especially pertinent to personality disorder because most patients find that many aspects of their lives and experience are inexplicable. Despite the therapist’s best efforts, invalidating events in treatment are almost inevitable. Patients are hypersensitive to invalidation and many tend “to test” the therapist to ensure that he or she does not behave as others have done (Weiss, 1993). Validation failures can be handled in the same way as ruptures to the alliance. First, the event is noted and the therapist acknowledges his or her contribution. Such interventions are validating and help to repair the rupture. Second, reactions to invalidation are explored including ideas about its causes and the patient’s perception of the therapist’s role in the process. The final step is to validate the patient’s responses. Handled in this way, modest validation failures afford useful opportunities to work on basic interpersonal schemata. Building motivation

A commitment to change is an essential ingredient of effective treatment. Motivation is needed to bring patients to treatment and to keep them in therapy because change is often a painful and frustrating process. This presents an ongoing

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problem because doubts about treatment, low motivation, passivity, and feelings of helplessness are inherent to personality disorder. These behaviors are often the longterm consequences of repetitive adversity and invalidating environments and hence remarkably resistant to change. Consequently, motivation cannot be a prerequisite for treatment. Instead, therapists need to be skilled in building and reinforcing a commitment to treatment, and be prepared to work on these issues throughout treatment. The motivational interviewing techniques described by Miller and Rollnick (1991, 2002) are often useful for this purpose. Motivation cannot be assumed even when dealing with such obviously harmful behavior as deliberate self-mutilation. Instead, a commitment to change needs to be elicited and regularly re-affirmed for each targeted problem. This commitment is built on the hope that treatment will be successful. Hope in turn is created by the way the therapist approaches treatment and by evidence that treatment decreases distress. For this reason, it is useful to begin treatment by setting modest and readily attainable goals, such as reducing self-harming acts, and by focusing on the more variable and readily treated components of personality pathology such as affective and impulsive symptoms. This approach is likely to yield modest successes early in treatment that can be used to build positive expectancies about treatment outcome. Besides fostering hope, it is also useful to discuss any dissatisfaction that the patient may feel about specific problems and life-style. Discontent is a powerful incentive for change. A common situation when treating personality disorder is for the therapist to recognize the harmful consequences of certain behaviors only for the patient to deny that it is a problem. This sometimes occurs with self-harming behaviors such as cutting that produce instant relief when the patient is in a dysphoric state. Under these circumstances, it is common for patients to assert that they do not want to relinquish these behaviors because they reduce distress and do not cause lasting harm. When this occurs, a focus on change when the patient is not committed to the process usually leads to deterioration in the treatment alliance. The best course seems to be to maintain the supporting stance and continue exploring the consequences of maladaptive behavior in the hope that this will promote recognition and acceptance of the negative consequences of these acts and hence initiate a commitment to change. Although clinicians are often prone to become more confrontational and coercive in these situations, such interventions do not appear to elicit the commitment sought. General treatment strategies and the organization of treatment

The search for the essential ingredients of effective treatments has led to the proposal that treatment be organized around generic mechanisms. These mechanisms, operationalized in terms of the four general therapeutic strategies, form the basic

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structure of therapy. They create a common thread that holds the therapeutic process together by ensuring that whatever else the therapist does, he or she always has an eye on the state of the alliance, the consistency of the process, the level of validation that is being achieved, and the patient’s commitment to change. Specific interventions taken from different therapeutic approaches may be added to the framework as needed to address specific problems. Although the general strategies remain constant throughout therapy, specific interventions vary according to the problems of individual cases and the issues that are the focus of attention at any moment. Under ideal circumstances, specific interventions would be selected on the basis of demonstrated efficacy for changing the problem behavior in question. Unfortunately, information on the effectiveness of specific interventions is limited. This means that the selection of specific interventions has to be based on a rational consideration of what interventions are likely to be most effective in managing a given problem. As several authors have noted (Clarkin et al., 1999; Linehan, 1993; Livesley, 2003), interventions form an approximate hierarchy of importance and priority. Priority is given to interventions needed to ensure the safety of the patient and others. Next, general strategies take priority over specific strategies because the conditions that these interventions are designed to promote are a prerequisite for effective use of specific interventions. A danger with eclectic therapy is that it can lead to an inconsistent form of treatment because therapists may be tempted to switch treatment strategies continually as they attempt to address the multiple problems raised by most patients. This outcome is avoided in three ways. First, the general treatment strategies help to create a stable treatment environment. Second, although specific interventions differ greatly across treatment models – the interventions of behavior therapy are often radically different from those of psychodynamic therapy – they share some common goals. Most specific interventions are intended to achieve three general outcomes: (1) increase self-knowledge or self understanding; (2) offer new experiences; and (3) foster new learning. Third, treatment may be conceptualized as progressing through an orderly sequence in which each phase addresses different components of personality pathology using a different array of interventions. Generic aspects of specific interventions

The development of self-knowledge is an almost universally recognized therapeutic factor: most therapies seek to extend patients’ views of their problems and enlarge the self by drawing attention to unrecognized aspects of self-experience and re-framing patients’ understanding of their problems. The self-knowledge that is sought is not confined to intellectual understanding but also involves changes in feelings and attitudes leading to an increased recognition of problem behavior

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and changes in the way these behaviors are experienced – a process that changes the way the self is experienced (Shapiro, 1989). In the process, events that were thought to be unrelated are seen to be the consequences of one’s own actions, and events that were considered unavoidable or inexplicable are seen to have causes. These changes in self-knowledge increase feelings of efficacy and control. The self expands as events, qualities, and feelings that were poorly understood or split-off are seen to be part of the self, opening up the possibility for further change. Most forms of therapy also encourage patients to confront aspects of their experience including memories, conflicts, and ways of behaving that are suppressed or avoided (Seltzer, 1986; Weinberger, 1995). This not only builds mastery and control but also promotes a greater sense of integration. An important part of the generic framework is the provision of new experiences inside and outside of treatment that challenge previous suppositions. These experiences take many forms. Some are short-term events such as corrective emotional experiences that occur when the therapist behaves differently from the patient’s expectations causing a re-examination and restructuring of pathological beliefs and expectations. Others are more enduring features of therapy. When treating personality disorder, a major task is to establish and maintain a treatment process that offers a continuous corrective experience that challenges enduring beliefs such as abandonment, rejection, and mistrust, which are central to the disorder. The emphasis on generic interventions is intended to offer such an approach. New experiences inside and outside treatment sessions also contribute to change by drawing attention to hitherto ignored or neglected parts of the self, challenging the beliefs underlying maladaptive behavioral patterns, and providing opportunities to confront fears and anxieties that previously felt overwhelming. In the process, new behaviors are learned and consolidated. Phases of change and intervention strategies

A further way to integrate and coordinate an eclectic array of interventions is based on the idea that treatment may be divided into five phases: safety, containment, control and regulation, exploration and change, and integration and synthesis (Livesley, 2003). The model is based on evidence that the features of personality and personality disorder differ in stability and amenability to change. Symptoms are the most variable with many symptoms varying naturally (see Grilo et al., 2004; Shea et al., 2002; Zanarini et al., 2005). An intermediate level of stability is formed by affect and impulse control mechanisms, maladaptive modes of thinking, cyclical maladaptive interpersonal patterns, dysfunctional cognitive styles, self-attitudes especially self-esteem, and maladaptive expressions of traits (although not the underlying disposition). Finally, traits (general tendencies as opposed to their behavioral manifestations), core schemata that are central to self and identity, and the structure of

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self and interpersonal pathology (unstable or fragmented representations of self and others) are highly stable and difficult to change. The plasticity of personality pathology establishes an approximate sequence for tackling problems. The safety, containment, and regulation and control phases of treatment focus primarily on symptoms and the dysregulation of emotions and impulses. The exploration and change phase largely addresses aspects of personality pathology that form an intermediate level of stability while integration and synthesis is concerned with fostering a more adaptive self structure, more integrated images of others, and more coherent interpersonal relationships – the most intractable aspects of the disorder. This sequence involves an early focus on the more malleable features of personality pathology to achieve a modicum of change early in treatment. It also incorporates interventions to build affect tolerance and emotional regulation skills before proceeding to deal with more emotionally arousing issues. The initial phase of safety occurs when treatment begins in a crisis state or whenever crises occur in ongoing treatment. The primary goal of ensuring safety of self and others is largely achieved by environmental manipulation and the provision of structure and support. Once safety issues are addressed, attention immediately focuses on containment with the goal of settling crisis behavior, containing impulses and affects, and restoring behavioral control. This is usually achieved through a continuation of structure and heavy reliance on support, validation, and empathic understanding supplemented with containment interventions and medication as appropriate. Containment interventions are supportive interventions based on the idea that in a crisis the patient’s primary concern is to obtain relief from distress and that relief comes from feeling understood (Joseph, 1983; Steiner, 1994). Hence the therapeutic task is to align with the patient’s distress (Vailliant, 1992) rather than confront it, try to change it, or interpret it. This approach is used whenever crises occur or emotional reactivity reaches levels that threaten to interfere with treatment. Safety and containment phases largely rely on generic interventions and environmental manipulation. The only specific intervention that is generally relevant is medication targeted on specific symptoms such as impulsivity, affective lability, or cognitive dysregulation (Soloff, 2000). Greater use is made of specific interventions in subsequent phases of treatment but always in the context of general treatment strategies. The third phase of control and regulation typically begins during crisis management but continues after the immediate crisis has settled. The goals are to reduce symptoms and promote self-management of emotions and impulses including deliberate self-harm. This phase is likely to be prolonged especially with severe personality disorder involving labile and reactive emotions. The limited evidence available suggests that the goals of the phase are best achieved by supplementing the general treatment strategies with specific cognitive behavioral and pharmacological

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interventions to increase affect tolerance and develop the skills needed to compensate for deficiencies in affect and impulse regulation arising from the interplay of genetic predisposition and psychosocial adversity. As affect regulation and tolerance are acquired and self-management improves, treatment gradually changes to the phase of exploration and change. During this phase greater emphasis is placed on exploring and changing the cognitive, affective, and motivational processes underlying problem behaviors. The issues addressed include maladaptive schemata associated with self-harming and violent behavior, maladaptive interpersonal behavior patterns, dysfunctional cognitive styles such as self-invalidating and catastrophic thinking, and the cognitive and behavioral consequences of trauma and other forms of psychosocial adversity. This is also the phase of treatment to begin addressing the maladaptive expressions of traits associated with clinically significant and socially deviant behavior. Here the goal is to attenuate the expression of such heritable traits as affective lability, impulsivity, and sensation-seeking and encourage more adaptive ways to express them. At this point, treatment often incorporates a rehabilitative element because the goal is not radical change in trait structure but rather helping the individual to use their traits more adaptively. The work of this phase requires the continued use of cognitive interventions to modify maladaptive schemata and dysfunctional ways of thinking. As treatment proceeds, however, less structured psychodynamic and interpersonal interventions may also be needed to deal with avoidant behavior and to confront, clarify, and change specific maladaptive patterns. Generic interventions continue to be important but these are often needed less during the middle phases of treatment. They become more prominent again late in the exploration and change phase as patients struggle with the frustrations of trying to implement new learning in everyday situations. The control-regulation and exploration-change phases of treatment cover the traditional work of therapy. Change involves substituting maladaptive thoughts, feelings, and behavior with more adaptive alternatives. In contrast, the final phase of treatment emphasizes integration and synthesis with the development of more adaptive self and interpersonal systems. This is primarily the work of long-term treatment. The goal is to integrate the fragmented nature of personality and synthesize new personality structures, especially more effective interpersonal boundaries, a more coherent self, more integrated representations of others, and greater self-directedness. Although there is little empirical research on effective intervention strategies, an analysis of the nature of self-pathology suggests that the systematic use of general therapeutic strategies is important and that the methods of self psychology and constructionist approaches to psychotherapy may be of value.

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This sequence brings order and structure to the treatment process by charting the broad course of treatment and providing a guideline that clinicians can use to select and integrate specific interventions from different therapeutic models within the context of a generic framework. However, the phases of change do not represent a rigid and fixed sequence. Treatment rarely follows a set trajectory: overlap and movement back and forth across the phases of change are the norm. Nevertheless, the sequence is a useful guide in treatment planning. Structured approach to treatment A second feature shared by effective treatments is a structured approach. “Structured” in this context refers to a systematic and explicit framework for establishing and organizing treatment rather than the type of interventions used. The frame is defined by the therapeutic stance, administrative steps taken to ensure treatment integrity, and the treatment agreement. Together these features create an agreed process for reaching collaborative treatment goals, establish the boundaries for therapy, and form the context for therapeutic interventions. The structure achieved helps to settle behavioral disorganization and emotional distress and lays the foundation for the continuous corrective therapeutic experience needed to change core self and interpersonal pathology. Therapeutic stance

The stance refers to the interpersonal approach, activities, and responsibilities that shape the interaction between patient and therapist (Gold, 1996). As even a brief observation of videotapes of therapy sessions reveals, the stance influences all aspects of the treatment process. The tone set by the therapist who adopts the more uninvolved style of classical psychoanalysis produces a very different pattern of interaction and flow of therapeutic material from that emerging when the therapist is warmer and more overtly empathic. Given the importance of the stance, it is unfortunate that little empirical information is available on the most appropriate stance for treating severe personality disorder. Nor is there complete agreement across different therapies. However, multiple considerations suggest that an important component of the stance is to provide support, empathy, and validation. First, this approach is fundamental to the generic approach discussed earlier. Second, it is similar to the position adopted by most authorities as exemplified by such concepts as mirroring (Kohut, 1971), empathic responding (Ryle, 1997), a holding and facilitating environment (Winnicott, 1960, 1965), and optimal responsiveness (Lichtenberg et al., 1992). Third, such an approach is consistent with etiological models that consider invalidation and self-invalidating ways of thinking important in the development and maintenance of personality pathology. Finally, empirical

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support for an empathic stance is provided by studies showing poor outcomes when therapists fail to relate to their patients in a warm and empathic manner regardless of their technical competence, and that patients with successful outcomes tend to describe their therapists as warm, attentive, interested, understanding, respectful, experienced, and active (Strupp et al., 1969). Besides emphasizing an empathic approach, most therapists also recommend a relatively high level of therapist activity (Ryle, 1997; Waldinger and Gunderson, 1989). Early in treatment, high activity helps to create the structure needed to settle unstable affects and promote engagement. Throughout therapy, activity emphasizes the therapist’s presence and contributes to the holding relationship that helps to anchor the patient in reality and reduce the tendency for severely disturbed patients to regress (Zetzel, 1971), become overwhelmed and disorganized, and dissociate (Ryle, 1997). Treatment contract

A common theme across therapies is the importance of an explicit treatment contract that defines the goals, purpose, and practical arrangements of therapy (Orlinsky and Howard, 1986). This agreement defines the spatial and temporal boundaries of therapy and establishes targets for change. Discussion of the therapeutic contract also helps to forge the idea that treatment is a collaborative process for which patient and therapist share responsibility. As Borden (1979) noted, the therapeutic bond, tasks, and goals are interdependent, and the strength of the treatment alliance depends on the level of agreement between patient and therapist about the goals and tasks of therapy. Most therapies, including Transference-Focused Psychotherapy (Clarkin et al., 1999), cognitive therapy, and Dialectical Behavior Therapy (Linehan, 1993), concur that the contract helps to establish a safe environment to contain reactive affects, selfdestructive acts, and maladaptive interpersonal behavior. They also emphasize the value of an explicit contract that includes an understanding of the responsibilities of patient and therapist, although there are differences in emphasis. Kernberg and colleagues (1989) use the contract to clarify the roles of therapist and patient and establish a therapeutic framework that permits interpretation of any deviations from the frame. The task is then to understand these deviations and confront the impact they have on therapy. This approach is also applied to impulsive and parasuicidal behaviors. The patient is not expected to cease these actions; rather, the therapist attempts to understand this behavior, encourages the patient to consider alternative ways to obtain help, and confronts the negative effect of such actions on treatment. Linehan’s (1993) position is similar, although the rationale differs (Hurt et al., 1992). The contract specifies the practical arrangements for treatment. There is also a substantial psycho-educational component that includes an explanation of

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the causes of parasuicidal behavior. As with Kernberg’s approach, patients are not expected to refrain from self-destructive and parasuicidal behavior; however, they must agree not to kill themselves while in treatment and agree to work toward the goal of reducing or eliminating such behavior (Linehan, 1993; Robins et al., 2001). For most therapies, the first step in developing a treatment contract is to establish treatment goals that reflect what the patient hopes to achieve in therapy as modified by the therapist’s understanding of what can realistically be accomplished given the patient’s problems and psychopathology and the resources available. Goals should be collaborative, realistic, and relatively specific. The process of discussing goals provides an early opportunity to engage the patient in a collaborative process. Once established, goals help to structure the treatment process and contain distress by focusing the patient’s attention on to specific problems that can be solved – a process that often facilitates change (Borden, 1994). The treatment contract includes practical arrangements such as appointment times, frequency and duration of sessions, likely duration of treatment, holidays, professional leave, and contact with the therapist between sessions. Discussion of these issues helps to establish treatment boundaries and reduces the chance of future misunderstandings. As with goals, a discussion of these arrangements also provides an opportunity to challenge unrealistic expectations about therapist availability, likely outcome, and how change can be achieved. Some events occurring during treatment can be predicted such as crises, requests for additional appointments or to prolong a particular session, and telephone calls between appointments. Hence it is helpful to decide in advance how these issues will be handled. This helps to ensure that they are handled consistently. It is also useful for the patient to be aware of these arrangements ahead of time. The development of explicit guidelines for dealing with these occurrences is not a matter of adopting rote responses; rather, it is an attempt to establish a set of principles to guide clinical decisions and reduce the chances of responding inappropriately under the pressure of events or countertransference. Discussion of the frequency of sessions is a convenient time to broach the topic of therapist availability between sessions in the event of an emergency. The position taken depends upon the therapist’s professional situation and the severity of the patient’s condition. This needs to be discussed before treatment not after problems arise. Sometimes the therapist’s professional circumstances prevent him or her from being available between sessions in which case a plan should be developed for the patient to follow in an emergency, such as attending an emergency room at a local hospital, contacting an agency that undertakes crisis intervention, contacting a support group, or visiting the family doctor. When it is possible for the patient to contact the therapist, the therapist should outline the ways in which he or she will be available and how the patient should initiate contact. Besides making these arrangements explicit, these matters need to be discussed in a way that does

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not convey an unrealistic impression of availability, encourage excessive contact between sessions, or imply that crises are inevitable or that the patient will not be able to manage them. The contract should also include an understanding of the likely duration of treatment. In some settings a limited number of sessions may be available. If these constraints apply they should be discussed frankly and treatment goals should be established with these limitations in mind. Any discussion of the duration of therapy should include a realistic discussion of the time required to effect major changes in personality disorder. Many patients (and some health care organizations) are attracted by short-term interventions. Patients need to realize, however, that although rapid progress is sometimes possible, long-term therapy is often required for lasting change in core pathology. Even cognitive therapists who normally advocate short-term therapy suggest that one to three years is required to treat more severe conditions such as borderline personality disorder (Layden et al., 1993). Some patients do not realize that their current problems are reflections of underlying problems and hence have unrealistic expectations of the duration of treatment. Others realize, however, that their problems are life-long and hence are unlikely to change quickly or easily. Such patients are often reassured by a frank discussion of time issues and many are content to have found a therapist who recognizes the need for longer-term treatment, something that they have intuitively felt was needed.

Consistency

The importance of a consistent therapeutic process was discussed earlier in the context of general treatment strategies. However, consistency does not only depend on intervening appropriately to frame violations. It is also influenced by the clarity of the treatment model, the context in which treatment occurs, and the availability of therapist support and supervision. Consistency is facilitated by an explicit treatment model. Hence most effective therapies are associated with a treatment manual that helps to ensure that therapists have an explicit understanding of therapeutic tasks and implement therapy in a reliable way. However, it is not sufficient to provide therapists with a clear understanding of what is required, it is also important to ensure compliance with the treatment model. Meta-analyses of the efficacy of forensic programs indicate that programme integrity – the extent to which treatment programs are delivered in a way that is consistent with their intent and design – has an important bearing on outcome (Hollin, 1995). Adherence to the model begins with the treatment context. In institutional settings, the institution needs to sanction and support the model adopted. Treating severe personality disorder is often difficult and frustrating. Consistency improves when therapists have access to support and consultation.

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In many situations, the treatment context has an important bearing on the process. Patients use context as a source of information about the therapist and treatment. When the treatment setting is a hospital outpatient department or a community mental health clinic, patients also interact with other staff besides their therapist. These interactions often color their interaction with the therapist. Under these circumstances, it is important to ensure that all staff understand the treatment model and adopt the same approach. Conceptual commonalities To this point discussion of the essential components of treatment has focused on the practical details of organizing and implementing therapy. The argument that current knowledge about severe personality disorder and treatment efficacy points to the merits of an eclectic and integrated model would be buttressed by the development of a corresponding conceptual framework that integrates different theoretical perspectives. Although we probably do not have sufficient empirical knowledge to construct a coherent theory of personality disorder and its development, it is possible to identify some conceptual similarities among the different perspectives on the pathology and pathogenesis of the disorder that have treatment implications. Unfortunately, some common themes are not supported by empirical evidence. For example, the almost exclusive emphasis placed by most psychotherapies on psychosocial adversity being the major etiological factor is not supported by studies demonstrating a substantial heritable component to DSM personality disorders (Torgersen et al., 2000) and personality disorder traits (Livesley et al., 1993, 1998). There are, however, other similarities that are not contentious. Perhaps the most substantive is the idea that the observable features of the disorder that are typical targets for intervention reflect problems in the cognitive structure of personality. Cognitive structure as an integrating concept

Such diverse models of personality and psychopathology as psychoanalysis, cognitive and cognitive behavioral perspectives, interpersonal models, and constructivism share the idea that the cognitive structures used to impose meaning and understanding of self, others, and the world are core components of personality (Barnett, 1980; Holt, 1989) and that reorganization of these structures is a major goal of treatment. Hence self and interpersonal constructs are potentially integrating concepts (Eells, 1997; Gold, 1996) in constructing a theory of personality disorder and conceptualizing treatment. Most therapies ignore this shared assumption. Instead of adopting a common language that would facilitate the integration of theory, research, and clinical practice, different terms are used to describe this structure, creating the spurious

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impression of distinctiveness. Thus these structures are variously labeled object relationships, working models (Bowlby, 1980), self and object representations (Gold, 1990a, 1990b; Ryle, 1990, 1997), cognitive schemata (Beck et al., 1990), and self or interpersonal schemata (Guidano, 1987, 1991; Horowitz, 1988a, 1998b). Although there are differences in the nuances of these concepts, all share the idea that constructs acquired during development are used to structure experience and plan action, and that maladaptive forms of these constructs are critical components of psychopathology that contribute to symptoms and maladaptive behavior. Integration would be facilitated by the adoption of a common language and terminology to describe these structures and the way they function. The term “schema” as used in cognitive science (as opposed to its more circumscribed use in cognitive therapy) seems the most fitting term for this purpose (Livesley, 2003). It is a relatively neutral term with a long history in psychology. Schemata are categories used to organize information, interpret experience, and guide action (Segal, 1988). Theories based on the concept of schema propose that knowledge is organized in units consisting of attributes (items of knowledge) and an explanation of how these attributes are connected (Komatsu, 1992; Rumelhart, 1980). For example, the schema of “bird” is more than a list of the different features or attributes such as wings, beak, feathers, and tail. It also includes an understanding of how the different anatomical structures are related to form a functioning organism that flies – although the depth of this understanding differs according to one’s knowledge of birds. Similarly, the schema of bicycle includes a list of parts such as wheels, pedals, seat, brakes, and handlebars and an understanding of how these parts work together. Schemata do not exist in isolation. Instead they are organized into a hierarchy. Thus schemata for specific birds such as owl or robin are part of the higher schema “bird” which in turn is part of an even higher order schema of “animal.” Schemata that are central to personality are not just cognitive structures, but also have an affective component. Many schemata originate in close interpersonal relationships so that the emotions experienced at the time become incorporated into the schema. Also schemata incorporate memories of specific events or examples of the concept that are memorable in some way, usually because they arouse strong feelings. For example, the schema of bicycle may include memories of one’s first bicycle. Because schemata are cognitive-affective units, the concept encompasses constructs such as object relations and working models and hence it has the potential to integrate different theoretical perspectives. Schemata and personality

The ideas that a schema consists of a set of attributes, an explanation of how and why these attributes go together, and memories of specific instances of the schema, and that schemata are arranged into a hierarchy are useful in understanding how information about self and others is organized. Personality is essentially an

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information processing system that appraises information about self and others and initiates action. Important parts of personality that are the focus of considerable therapeutic activity may be conceptualized as knowledge systems that store, organize, and encode information. In the case of interpersonal structures, schemata are formed to handle information about relationships, specific individuals, and particular groups such as men, authority figures and so on. Relationship schemata such as rejection, abandonment, and mistrust consist of beliefs and expectations forged in early experiences that color most aspects of the individual’s interactions with others. In the case of specific individuals, information about that person – their personal qualities, values, beliefs, and interests – is organized into a representation or schema of that person. For most healthy individuals an interpersonal schema is not simply a list of that person’s qualities. Rather it is an organized account that includes an understanding of how the person’s different qualities relate to each other. When someone is merely an acquaintance, the schema is probably confined to a few salient qualities such as whether the person is reliable, pleasant, approachable, and so on. When someone is well-known, the schema is detailed and often includes an understanding that there are different facets to the person. For example, we may think of another person as being friendly, kind, and cheerful at times but also as irritable and disagreeable on other occasions. Usually some attempt is made to reconcile these apparent discrepancies. For example, we may recognize that a person is normally friendly and cheerful but irritable when stressed. Schemata also incorporate memories of things the person did, important experiences shared with them, and so on. These memories are usually salient because they evoke strong feelings. The overall schema of another person is hierarchically organized. Specific attributes such as friendly or irritable are lower level schemata that are organized into the higher level schemata that represent the different images of that person. These images are in turn organized into a coherent representation of the person. With personality disorder it is common for the schema of another person to have impoverished or stereotyped content and for the different images of the other to remain separate rather than integrated into a global representation of that person. The self system is organized along similar lines. A schema of the self as “caring” consists of behaviors such as “being helpful,” “responding to other’s needs” and being “attentive to someone’s well-being.” The schema of caring may be associated with other attributes to form a more global schema of the self. Most people have multiple self-images. They think of themselves differently in their various roles of offspring, parent, partner, employee, friend, and so on. The schemata representing these different self-images are linked to form a higher-order conceptualization of the self, culminating in an overarching self-view or autobiographical self. Severe personality disorder usually involves problems in the structure of the self. These

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include an impoverished understanding of the self as is often the case in schizoid personalities or a fragmentation of the self due to the failure to integrate different self schemata into a coherent structure, as is often the case with borderline pathology. Self and interpersonal schemata underlie interpersonal behavior. Schemata appraise and encode information from external and internal sources and action initiated. With interpersonal events, another person’s behavior activates a salient schema that creates a state within the observer (a want, wish, goal, or expectation) that gives rise to various actions. These actions are observed by the first person who responds accordingly. This response is noted by the observer. This chain of events is often repetitive and circular because actions initiated by a schema tend to elicit responses from others that confirm the schema. For example, a suspicious person may decide that another person cannot be trusted and thus acts cautiously toward them. This in turn is likely to elicit a distrustful and cautious response that confirms the initial impression. The repetitive nature of maladaptive interpersonal patterns also occurs because schemata tend to be self-perpetuating: they influence what is noticed and the way events are interpreted. The combination of cognitive factors leading to selective attention to, and interpretation of, events and behavioral factors that lead to actions that elicit confirming responses creates considerable stability in schemata and associated interpersonal patterns. Clinical implications

Most therapies share assumptions that maladaptive cognitive structures and processes underlie many of the problem behaviors that define clinical presentations and that an important goal of therapy is to change, or at least modulate, maladaptive schemata and associated patterns of maladaptive interpersonal behavior. When treatment is conceptualized in this way, links among different therapies become more apparent leading to opportunities to combine and integrate intervention strategies across treatment models. Given the extent to which schemata are stable and resistant to change, it seems counterproductive not to use all of the change methods that are available regardless of their theoretical heritage. This section will briefly consider similarities across models in the conceptualization and management of symptoms and crises and the exploration and change of enduring schemata and associated interpersonal behavior to illustrate the application of an eclectic approach based on generic mechanisms. Conceptualization of crises and symptoms

Strategies for managing common symptoms such as deliberate self-harm differ greatly across treatments. Psychoanalytically based treatments such as TransferenceFocused Psychotherapy (Clarkin et al., 1999) are primarily concerned with explicating object relations at the level of the unconscious that are activated by triggering

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events. Deliberate self-harming acts are considered expressions of these activated object relations units (Swenson, 1989). Changes in self-harming behavior and associated affects are assumed to result from modification of object relations units rather than interventions targeted specifically at these behaviors. In contrast, behavioral therapies such as Dialectical Behavior Therapy (DBT, Linehan, 1993) specifically focus on self-harm and the escalating emotional states that lead directly to these acts. The intent is to reduce self-harm using behavioral strategies to reduce the expression of these behaviors and promote alternatives and to use a skill-building approach to increase affect tolerance and self-regulation. Despite manifest differences in intervention strategies, psychoanalytic and cognitive behavioral theories hold similar assumptions about the sequence of events that lead to such problem behaviors as deliberate self-harm (Swenson, 1989). As Swenson noted, Kernberg’s transference-focused model (Clarkin et al., 1999) and Linehan’s (1993) DBT concur that the sequence of events leading to self-harm involves: (1) some kind of triggering environmental event that leads to (2) an escalating dysphoric state; this state is associated with (3) efforts to manage the dysphoria leading finally to (4) deliberate self-harm. The two approaches also agree that the triggering event is usually interpersonal such as a rejection. Such events are significant because they activate core schemata. Both models also acknowledge the influence of constitutional factors. They differ in that Kernberg emphasizes the importance of intrapsychic events and unconscious processes throughout the sequence whereas Linehan is more concerned with deficits in the skills needed to regulate and control emotions and the reinforcement of problem behavior. Despite these differences, overall agreement about the sequence furnishes an opportunity to develop an integrating framework for conceptualizing and managing deliberate self-harm. Each of the four stages leading to deliberate self-harm is a potential interventions target. Cognitive behavioral therapies have a larger array of interventions to decrease self-harming acts and improve skill deficits. Cognitive therapies seem better equipped to deal with underlying maladaptive schemata and psychodynamic therapies appear especially suited to resolve associated conflicts and address avoidance behaviors that impede treatment. Given that most of the behaviors involved in deliberate self-harm are multi-determined and resistant to change, there is merit in a multi-pronged approach in which a given problem is addressed using multiple interventions drawn from different schools of thought, especially since most interventions are comparatively weak. Changing maladaptive schemata and interpersonal patterns

Identification, exploration, and change of maladaptive cognitions and interpersonal patterns can also benefit from the use of psychodynamic, cognitive, and behavioral interventions. Psychodynamic therapies are particularly effective in facilitating the

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identification of broad schemata and interpersonal patterns. The careful attention to the therapeutic relationship that is characteristic of psychodynamic therapies facilitates the recognition of global schemata and behavior patterns such as abandonment, rejection, submissiveness, and suspiciousness as they occur in treatment. In contrast, behavior therapy excels in detailed behavioral analysis. This is useful in helping patients to recognize how these patterns are expressed in everyday interaction and the reinforcement contingencies that maintain them. This approach offers an independent contribution to change because it is easier to change specific behavior than global patterns. Viewed in this way, the two approaches are not alternative ways of changing cognitive structure but rather complementary approaches that can make separate contributions to the change process. There is also convergence on assumptions about the most effective way to change maladaptive schemata. Cognitive therapies describe cognitive, interpersonal, behavioral, and emotional methods (Beck et al., 1990; Cottraux and Blackburn, 2001; Padesky, 1994; Young, 1990, 1994). However, there is some agreement that standard cognitive interventions are not as effective in treating severe personality disorder as they are other disorders (Layden et al., 1993). Instead, greater emphasis is placed on interpersonal methods that use the therapeutic relationship as a major vehicle for change (Young, 1994; Young et al., 2003). The way the patient perceives and relates to the therapist is an important source of information about maladaptive schemata. The activation of these cognitions in therapy provides a valuable opportunity to help patients to recognize how schema operate and challenge maladaptive cognitions as they occur in real time. This emphasis is similar to the traditional use of the transference as the primary change mechanism in psychoanalytic therapy. Contemporary applications of psychoanalytic methods to the treatment of severe personality disorder place greater emphasis on using the transference as a tool to explore maladaptive schemata in the here-and-now of therapy and less emphasis on historical reconstruction. Thus there are close parallels with Young’s schema-focused therapy. Hence during this phase of treatment, a combination of cognitive, interpersonal, and psychodynamic interventions offers the most effective way to bring about change. Generic interventions continue to be important but often the need for these interventions decreases during the middle phases of treatment. Conclusions The search for the essential components of effective treatments identified similarities in change mechanisms, the organization and implementation of treatment, and the conceptual underpinnings of currently popular approaches. This led to the argument that the evidence supports an eclectic and integrated approach. The

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argument was based on evidence that different treatments do not appear to produce substantially different results although there is a little evidence that some specific problems respond better to some intervention strategies than others. Based on these considerations it was proposed that treatment be organized around generic change mechanisms and that an eclectic array of specific interventions be added to this structure as needed to tailor treatment to the individual patient. Such an approach offers a practical and evidence-based approach that is easily adapted to different treatment situations, different treatment programs, and the therapist’s style. When examining the essential elements of treatment, personality disorder was largely treated as a general condition with little attention to the different disorders listed in contemporary nomenclatures. The reason is the assumption that the similarities across disorders – the core features of personality disorder in the form of self and interpersonal pathology – are more important for treatment than individual differences in the personality constellation. The common features of personality disorder are responsible for the difficulties often encountered in establishing the collaborative therapeutic alliance and the consistent treatment process needed for effective treatment. This does not mean, however, that individual differences in personality constellations are unimportant. Four broad constellations of traits underlie personality disorder diagnoses (Livesley, 1998; Widiger and Simonsen, 2005): the emotional dysregulation or borderline pattern, dissocial or psychopathic pattern, inhibited or schizoid avoidant pattern, and compulsivity. Although the common elements are basic to treating all patterns, both generic and specific interventions need to be tailored to these personality profiles. Despite the exaggerated claims made about the efficacy of some therapies, the treatment of personality disorder is still at an early stage. Intervention strategies are comparatively weak, outcomes are modest, and none of the approaches currently in common use are broad enough to encompass the phenomenological and etiological diversity of the disorder. Eclecticism and conceptual integration across models appears to offer the most promise in laying the foundation for a more effective approach. To achieve this, empirical investigations need to be less concerned with comparing different modestly effective therapies and more concerned with determining the most effective intervention strategies for each domain of personality pathology.

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Index

ACT (assertive community treatment) 169–172 ADHD (attention deficit hyperactivity disorder) 86, 88 adolescents 82, 84–85, 87 adoption studies 80 aetiology see etiology affect, lacking in psychopaths 183–184 affect representation 33 affective dysregulation pharmacotherapy 146, 147, 149, 151, 153, 154 recommendations 140, 158–159 psychotherapy 123 aggression in antisocial personality disorder (ASPD) 17 in children 83 countertransference and 46 pharmacotherapy 140, 157–158 see also violence alprazolam 153–154 American Psychiatric Association (APA), guidelines for treatment 137, 140–141, 168, 173 amitriptyline 143, 146 anger management 169, 178 pharmacotherapy 140, 159 poor prognosis 167 in stalkers 197, 200, 204 anticonvulsants see mood stabilizing drugs antidepressants efficacy 143, 146–149 monoamine oxidase inhibitors (MAOIs) 140, 143, 147, 159 mianserin 148 recommendations for use 140, 157, 158, 159 selective serotonin reuptake inhibitors (SSRIs) 140, 148–149, 157, 158 side-effects 147, 148 tricyclic 143, 146–147, 157 antipsychotics in children 88 discontinuation rates 61 efficacy 142–147

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recommendations for use 140, 141, 156–157, 158, 159 side-effects 144, 146 antisocial personality disorder (ASPD) prevalence 181 treatability 17–19, 24, 167 see also psychopathy anxiolytics 140, 153–154, 159 apologizing to patients 51, 103 arrogance 52 ASPD see antisocial personality disorder assertive community treatment (ACT) 169–172 atomoxetine 88 attachment theory 32, 81–82 attention deficit hyperactivity disorder (ADHD) 86, 88 babies, attachment 81–82 bastions in therapy 45 benzodiazepines 140, 153–154, 159 bitterness 7 borderline personality disorder (BPD) countertransference and 44, 165, 166, 171, 176–177 diagnosis 12, 120, 166 epidemiology 119 etiology 83–84 maternal 81 refractory patients characteristics of 166–168, 176–177 families of 173, 175–176 support for professional carers 176–177 treatment 164–166, 168–175, 177–178 suicidality hospitalization 111–112 risk of 10, 12, 14–15, 110, 167 therapists’ attitudes to 165 treatment choice of setting 120–122 day hospitals 124, 127–128 hospitalization 111–112, 172–175 mentalization and 127–133 outcome studies 9–15, 18, 23–24 outpatient 169–172, 174–175

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Index patient–therapist relationships 6–7, 35–39 pharmacotherapy 138, 143–160 refractory patients 164–166, 168–175, 177–178 strategic reviews 118 boredom 53 BPD see borderline personality disorder calming techniques 102 carbamazepine 150–151, 158 character 5 in narcissistic personality disorder (NPD) 5–6 traits promoting well-being 62–66, 67 children 89 abuse and neglect 14–15, 83–84 sexual abuse 13, 14, 84, 167 developmental psychopathology 60, 79–84 diagnosis of personality disorders (PDs) 84–85 prevention of PDs 87 psychopathological types related to PDs 18–19, 85–87 treatment of PDs 87–88 choice of treatment integration of strategies 211–234 matching patients and therapists 6–7, 33–39 matching patients and treatments 30–33, 39–40, 74 clozapine 157 cognitive behavioral therapy 3, 22, 24, 88, 232, 233 cognitive perceptual symptoms, pharmacotherapy for 141, 156–157 coherence of thought 72–74 communications breakdowns 93–106 community treatment see outpatient treatment complaints, malicious, by stalkers 201–202, 207 complementary countertransference 45–47 concordant countertransference 45 conduct disorder (CD) 85 confidentiality 192–193 conflict avoidance 95–96 conflict and deficit models 97 consistency, importance of 175, 217, 227–228 contemplation 67, 71 contracts 34, 168, 213, 225–227 cost issues day hospitals 128 hospitalization 112 modes of treatment compared 121 countertransference acting out 45, 50–51, 55–56 acute or chronic 46, 47–48 analysis of 48–51, 54 BPD patients and 44, 165, 166, 171, 176–177 complications in treatment 51–54 concordant or complementary 45–47 psychopathic patients and 186–190, 192 technical neutrality 43, 51, 56–57 theories of 42–44, 54–57 credulous listening 102, 104

day hospitals 122–127 Mentalization-Based Treatment (MBT) 127–128, 129–130 for suicidality 113 DBT see Dialectical Behavior Therapy “dead mother” syndrome 53 DeBardeleben, Michael 21 deceitfulness as barrier to treatment 5 in psychopaths 184, 191, 192 deficit and conflict models 97 denial (by therapists) 188, 205 dependent personality disorder 8–9 depression morbidity 60 pharmacotherapy 61, 143, 145, 159 psychopathy and 191 psychotherapy 53, 63 stalking and 208 suicide risk 11, 14 desipramine 146 developmental theory causes of psychopathology 79–84, 128–129 disruptions and 104–105 DFT (Diagnosis of Frequency of Thought) 72–74 diagnosis BPD 12, 120, 166 in children 84–85 choice of treatment and 32 difficulty in 2, 166 psychopathy 20, 185–186, 191 Diagnosis of Frequency of Thought (DFT) 72–74 Dialectical Behavior Therapy (DBT) not for feelings of hopelessness 63 for self-harm 13, 114, 232 therapeutic setting 114, 123 validation strategies 217 differential therapeutics 31 disruptions during therapy 93–106, 216–217 disruptive attunement 104–105 disruptive behavioral disorders see externalizing childhood disorders dissociative symptoms 154, 156, 157, 167 divalproex (valproate) 151–152, 159 dysmorphophobia 198 dysthymia 11 see also depression E-EPA (ethyl-eicosapentaenoic acid) 154 efficacy pharmacotherapy antidepressants 143, 146–149 antipsychotics 142–147 benzodiazepines 153–154 mood stabilizing drugs 149–153 omega 3 fatty acids 154 opiate antagonists 154 problems with evidence for 137–138, 141–142 psychotherapy 9–25 day hospitals 124–128

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Index E-EPA (ethyl-eicosapentaenoic acid) (cont.) difficulty in comparing 212–213 inpatient 18, 173, 227 treatment setting and 120–122 egocentricity 2 emergencies, handling of 226–227 suicidal crises 114–115 empathy 3 failure of in therapists 97–98, 103 lacked by psychopaths 20, 21, 183 empirically supported treatment 30, 31, 212 environmental factors 80–84 in psychopathy 191 severity of outcome and 167–168 envy 96 epidemiology antisocial personality disorder (ASPD) 181 borderline personality disorder (BPD) 14, 119 stalking 196, 198–200 suicide 14, 109–110 ethyl-eicosapentaenoic acid (E-EPA) 154 etiology 32, 79–84, 167–168, 228 evidence-based medicine see guidelines for treatment externalizing childhood disorders 85–86, 88 extraversion and intraversion 83 families as carers 173, 175–176 child development and 80–82, 104 genetic studies 79–80 prevention and treatment of childhood PDs 87, 88 as source of patients’ guilt 95 of victims of stalking 206 fathers 104 fear in definition of stalking 197 as a reaction to psychopathic patients 187–188 females childhood development of PDs 88 effect of SSRIs 149 fetal factors 80–81 fluoxetine 145, 148–149 flupentixol 143 fluvoxamine 149 forensic hospitals 18, 19, 227 fuzzy sets 1–2 gender differences borderline personality disorder (BPD) 11 childhood development of PDs 88 effect of selective serotonin reuptake inhibitors (SSRIs) 149 stalking 200 genetics 79–80 group psychotherapy 123–124, 126–127, 129 guidelines for treatment 118 hospitalization for suicide risk 173 pharmacotherapy 137, 140–141, 156–160 pre-therapy contract 168 guilt 95

haloperidol 143 happiness 59–60, 69–70 see also well-being Hare Psychopathy Checklist (PCL-R) 8, 20, 185 hatred of patients 189 heredity 79–80 histrionic personality disorder 24, 148 holding environment in therapy 101 homeostatic attunement 104–105 hospitalization compared with other modes of treatment 120–122 forensic hospitals 18, 19, 227 leading to deterioration 111–112 for refractory patients 172–175 for suicidality 111–112, 173 see also day hospitals hypothalamic–pituitary–adrenergic axis 80, 84 impulsive behavior pharmacotherapy 145, 146, 149, 150, 151–153, 154 recommendations 140, 157–158 in prognosis of borderline personality disorder (BPD) 167 infants, attachment 81–82 integration of treatment strategies 211–234 internalizing childhood disorders 85, 86 intraversion and extraversion 83 irritability 24 lamotrigine 153 legal issues litigation after a suicide 112 stalking 197, 207–208 in treatment of psychopathic patients 192 lithium 150, 158 males borderline personality disorder (BPD) 11 childhood development of PDs 88 effect of selective serotonin reuptake inhibitors (SSRIs) 149 malignant narcissists 5, 24 Manson, Charles 18 MAOIs see monoamine oxidase inhibitors masochistic patients 51–52 MBT (Mentalization-Based Therapy) 114, 127–128 MCDD (multiple complex developmental disorder) 86, 87 medication see pharmacotherapy meditation 68 men see males mental health professionals support for 176–177, 205–206, 208 working in teams 171–172, 175, 177 see also therapists mentalization 128–133 see also self-awareness Mentalization-Based Therapy (MBT) 114, 127–128

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Index meta-cognition 67, 71 methylphenidate 88 mianserin 148 mindfulness training 63 monoamine oxidase inhibitors (MAOIs) efficacy 143, 147 recommendations for use 140, 159 mood stabilizing drugs carbamazepine 150–151, 158 efficacy 149–153 lamotrigine 153 lithium 150, 158 recommendations for use 140, 158, 159 side-effects 150, 151 topiramate 152–153, 158 valproate 151–152, 159 motherhood constellation 80 mothers child development and 80–82 homeostatic attunement 104 as source of guilt 95 motivation affecting treatability 3, 11, 74 building 72, 218–219 multiple complex developmental disorder (MCDD) 86, 87 naloxone 154 naltrexone 154 narcissistic personality disorder (NPD) 5–6, 24, 217 countertransference 53 malignant narcissists 5, 24 NPD × BPD 14 neuroendocrinology 80–81, 84 neuroleptics in children 88 efficacy 142–144 recommendations for use 140, 141, 156, 158, 159 see also antipsychotics neurotic disorders 124 see also depression neutral psychotherapists 171–172, 174 NPD see narcissistic personality disorder olanzapine 144–145, 158 omega 3 fatty acids 154 opiate antagonists 154 oppositional defiant disorder (ODD) 85 outpatient treatment 114, 228 assertive community treatment (ACT) for refractory patients 169–172 step-down programs 120–121, 125, 174–175 paranoid personality disorder 8–9, 24 parasuicidal behavior see self-destructive behavior parent management training (PMT) 88 parents see families patients causes of disruptions to therapy 95–97 characteristics affecting treatability 3–8, 22

characteristics affecting treatment choice 32–33 matching with therapists 6–7, 33–39 PCL-R (Psychopathy Checklist-Revised) 8, 20, 185 personality temperament 82–83 theories of 81–82, 228–233 treatability and 3–6 Peterson, Scott 184 pharmacotherapy antidepressants efficacy 143, 146–149 recommendations for use 140, 157, 158, 159 side-effects 147, 148 antipsychotics discontinuation rates 61 efficacy 88, 142–147 recommendations for use 140, 141, 156–157, 158, 159 side-effects 144, 146 benzodiazepines 140, 153–154, 159 for children 88 conceptual models 138–139 discontinuation rates 61, 142, 147 evidential weaknesses 137–138, 141–142, 159–160 guidelines 137, 140–141, 156–160 limitations of 61 mood stabilizing drugs efficacy 149–153 recommendations for use 140, 158, 159 side-effects 150, 151 omega 3 fatty acids 154 opiate antagonists 154 for suicidal behavior 114, 143, 148 phenelzine 143, 147 post-traumatic stress disorder (PTSD) 84 Practical Guideline for the Treatment of Patients with Borderline Personality Disorders (APA) 137, 140–141, 168, 173 pregnancy 80–81 prevalence antisocial personality disorder (ASPD) 181 borderline personality disorder (BPD) 119 stalking 198, 199 prevention early intervention 87 of suicide 110, 113 prognosis see treatability projective counteridentification 47, 52 projective identification 45–47 psychodynamic therapy characteristics 122, 123, 217 strengths 22, 232 weaknesses 3, 24 see also transference-focused psychotherapy psychological mindedness (PM) 126 psychopathy characteristics of 17, 18, 181–185 countertransference reactions 186–190, 192 diagnosis 20, 185–186, 191

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Index psychopathy (cont.) treatment 3, 19–22, 183, 190–193 see also antisocial personality disorder Psychopathy Checklist-Revised (PCL-R) 8, 20, 185 psychotic-like symptoms, pharmacotherapy 141, 144, 156, 157 quality of object relations (QOR) 126 record-keeping 112, 207 regression countertransference and 44 disruptions in therapy and 95–97 in hospitalization 111, 173 risperidone 88, 144, 145 Rorschach test 186 sadistic personality/sadism as cause of disruptions 96 (un)treatability of 19, 21, 24 see also psychopathy safety of therapists 50–51, 52, 102 when treating psychopathic patients 187–188, 192–193 see also stalking schizoid personality disorder 24, 86 schizophrenia 61, 87, 191, 204 schizotypal personality disorder (STPD) childhood precursors of 86 pharmacotherapy 138, 143, 144, 145, 156 treatability 15–17, 24, 124 selective serotonin reuptake inhibitors (SSRIs) efficacy 148–149 recommendations for use 140, 157, 158 self-awareness/self-knowledge 64 as goal of therapy 220–221 lack of 66, 72–74 mentalization 128–133 stages 66–67, 70–71 self-control 82, 86 self-destructive behavior 109 in the therapeutic contract 226 treatment 13, 112, 154, 219, 231–232 see also suicidality self-directedness 62–63 self-esteem 105 self-help 68–70 self psychology 217 self-transcendence 60, 64–65 separation anxiety 96–97 sexual abuse in children 13, 14, 84, 167 sexual attraction towards patients 50, 51, 190 “Silence of the Mind” meditation 68 skeptical listening 102, 105 socioeconomic status 20 sociopathy see antisocial personality disorder Soloff, P.H., treatment algorithm of 140–141 spirituality and spiritual development 64–65, 68–72 split treatment 171–172, 174

SSRIs see selective serotonin reuptake inhibitors stalking 208–209 epidemiological studies 196, 198–200 examples 5, 100 management of 197, 205–208 stalker characteristics 196–197, 200–201, 202–203, 204–205 victim characteristics 196, 197–198, 201–202, 203–204 step-down programs 120–121, 125, 174–175 STPD see schizotypal personality disorder stress as cause of PDs 80–81, 84 reduction techniques 70 stalking and 208 substance abuse 167, 191 suicidality 109 borderline personality disorder (BPD) hospitalization 111–112 risk of 10, 12, 14–15, 110, 167 therapists’ attitudes to 165 BPD × NPD 14 countertransference and 54, 165 prediction 14, 109–110, 167 prevention 110, 113 treatment chronic suicidality 113–114 crises 114–115 day-patient 113 inpatient 111–112, 173 outpatient 114 pharmacological 114, 143, 148 see also self-destructive behavior surgency 83 Surviving Stalking (Path´e) 205 survivor’s guilt 95 teamwork 171–172, 175, 177 technical neutrality 43, 51, 56–57 telephone contact 114 temperament, childhood 81, 82–83 Temperament and Character Inventory (TCI) 62 TFP see transference-focused psychotherapy therapeutic alliances 168 building 72, 170–171, 215–217 contracts 34, 168, 213, 225–227 disruptions to 93–106, 216–217 importance of 214 lack of 168, 183, 187 therapeutic communities 122 therapeutic nihilism 19, 186 therapeutic stance 224–225 therapists causing disruptions to therapy 97–98, 103 characteristics affecting outcome 23, 33–34, 75, 133, 225 countertransference reactions see countertransference matching with patients 6–7, 33–39 safety 50–51, 52, 102, 187–188, 192–193 see also stalking

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Index treatment of psychopaths 183, 184, 186–190, 192–193 thiothixene 143 thought disorders, childhood 85, 86 “three person psychology” 35, 54–56 topiramate 152–153, 158 torture, treatment of victims 45 trait vulnerabilities 139 transference countertransference and 44, 54 leading to stalking 202–203 use in treatment 233 transference-focused psychotherapy (TFP) 44 matching patients and therapists 33–39 for self-destructive behavior 13, 231–232 tranylcypromine 147 trauma as a cause of borderline personality disorder (BPD) 84, 129 causing bastions in therapy 45 treatability 22–25 antisocial personality disorder 17–19, 24, 167 borderline personality disorder 9–15, 18, 22, 23–24, 118 refractory patients 165–166

dependent personality disorder 8–9 diagnostic category and 1–2 estimating 8–11 histrionic personality disorder 24 narcissistic personality disorder 24 paranoid personality disorder 8–9, 24 patient characteristics 3–6, 22 psychopathy 3, 19–22, 183 schizotypal personality disorder 15–17, 24 therapist characteristics 6–7, 33–34 tricyclic antidepressants 143, 146–147, 157 trifluoperazine 143 twin studies 79, 80 validation 217–218 valproate (divalproex) 151–152, 159 violence in psychopaths 184–185, 192–193 by stalkers 200 see also aggression Voyages to Well-Being (Cloniger) 68–70 walk outs 101 well-being 59–75 women see females