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Practical Management of Personality Disorder
By W. John Livesley
The Guilford Press Copyright © 2003 The Guilford Press
All right reserved.
Chapter One General Therapeutic Strategies
Earlier discussion of core pathology and the results of psychotherapy outcome studies led to the proposal that treatment should be organized around generic change mechanisms. This chapter extends these ideas by considering the strategies and interventions required to implement this proposal. Four strategies are suggested:
1. Building and maintaining a collaborative relationship.
2. Maintaining a consistent treatment process.
3. Establishing and maintaining a validating treatment process.
4. Building and maintaining motivation for change.
These strategies are independent of the type and duration of treatment, the theoretical orientation of the therapist, and individual differences in patients' personalities and psychopathology.
The consistent use of these strategies brings about changes in core pathology by drawing the patient into a more adaptive relationship. Emphasis on collaboration builds the treatment alliance and addresses problems in working cooperatively with others. A consistent treatment process provides a predictable therapeutic relationship that modifies expectations of inconsistency and unpredictability arising from earlier dysfunctional relationships. Validatinginterventions convey support and build the alliance. They also help to correct self-invalidating ways of thinking that hinder the formation of a coherent self. Finally, efforts to build motivation create the commitment necessary for change and help to modify beliefs of powerlessness, passivity, and limited self-efficacy that contribute to low self-esteem and perpetuate maladaptive patterns. These strategies also establish the therapeutic relationship and structure required for the effective use of the specific interventions that form the second component of treatment.
The first three strategies largely use interventions that are relationship-based rather than change-focused. Interventions for building motivation, which also incorporate a change-focused element, form a bridge between the general strategies and specific interventions that are more directly concerned with behavioral change.
STRATEGY 1: BUILD AND MAINTAIN A COLLABORATIVE RELATIONSHIP
Priority is given to building and maintaining the alliance because a collaborative therapeutic relationship is inherently supportive and central to managing core pathology. Most treatments emphasize the importance of a collaborative relationship, including psychoanalytic therapy: (Buie & Adler, 1982; Masterson, 1976; Zetzel, 1971), cognitive therapy (Beck et al., 1990), interpersonal therapy (Benjamin, 1993), and dialectical behavior therapy (Linehan, 1987, 1993; Robins et al., 2001). Moreover, a poor alliance early in treatment predicts early termination (Frank, 1992; Hartley, 1985; Horvath & Symonds, 1991; Luborsky et al., 1985; Raue & Goldfried, 1994), and improvement in the alliance during treatment is associated with positive outcomes (Foreman & Marmar, 1985; Luborsky et al., 1993; Westerman, Foote, & Winston, 1995). Although these conclusions are based on the general psychotherapy literature, studies of personality disorder point to similar conclusions (Horwitz, 1974).
Contemporary conceptions emphasize that collaboration is the critical feature of the alliance (Gaston, 1990; Hatcher & Barends, 1996; Horvath & Greenberg, 1994; Luborsky, 1984). Unfortunately, therapists from most schools agree that a collaborative relationship is difficult to achieve with this population. As Benjamin (1993) noted, "The hardest part of treating personality disorder is helping the patient collaborate against 'it,' the longstanding way of being" (p. 240). It takes time for the alliance to emerge and consolidate (Horwitz, 1974). Indeed, an effective alliance is more the result of successful treatment than a prerequisite for it (Frank, 1992).
Many factors hinder alliance formation. Many patients lack the relationship skills required for collaborative work. Psychosocial adversity leads to caution about relationships and negative expectations about help and support. Feelings of envy, conflicted attitudes toward authority, and dependency conflicts interfere with the process, as do maladaptive traits. Emotional dysregulation, for example, tends to produce emotionally driven relationships that are unstable. Inhibited individuals, on the other hand, tend to avoid contact with the therapist. Because of these factors, throughout treatment priority is given to building, maintaining, monitoring, and repairing the alliance (Beck, 1995; Beck et al., 1990; Benjamin, 1993; Chessick, 1979; Cottraux & Blackburn, 2001; Meissner, 1984, 1991; Young, 1990, 1994). It may take several months or even years to establish an effective alliance (Masterson, 1976). Empirical studies show that even after 6 months, a good alliance has not been achieved with most borderline patients (Frank, 1992). Subsequently, the alliance is likely to fluctuate: Any deepening of the relationship is likely to evoke feelings of vulnerability, leading to a decrease in the alliance. Work on the alliance typically begins during assessment; patients entering therapy with negative attitudes, hostility, and reluctance to engage in the therapeutic process have poor outcomes (Strupp, 1993). An emphasis on the collaborative nature of the alliance makes it clear that both partners contribute to the relationship. Descriptions of the working relationship consistently stress (1) the affective bond that the patient establishes with the therapist; (2) the patient's commitment to therapy and capacity for purposeful therapeutic work; (3) the therapist's empathic understanding of the patient and involvement in therapy; and (4) the agreement between the patient and therapist on the goals of therapy (Gaston, 1990). These relationship dimensions remind therapists to separate their contribution to the alliance from that of their patients, and to bear in mind that they, too, may contribute to alliance problems.
Luborsky (1984, 1994; Luborsky, Crits-Christoph, Alexander, Margolois, & Cohen, 1983) offered a conceptualization of the alliance that is especially helpful in treating people with personality disorder. For Luborsky (1994), the alliance "is an expression of a patient's positive bond with the therapist who is perceived as a helpful and supportive person" (p. 39). Drawing upon empirical studies, he proposed that the alliance has a perceptual component, in which the patient perceives the therapist and therapy as helpful and supportive and him- or herself as accepting help, and a relationship component in which the patient and therapist work together to help the patient.
Strategies for Building and Strengthening the Alliance
The evidence suggests that the alliance is fostered by (1) maintaining a focus on the relationship between patient and therapist, and (2) the therapist adopting a collaborative style that focuses on the patient's goals and current concerns (Horvath & Greenberg, 1994; Luborsky, Crits-Christoph, Mintz, & Auerbach, 1988). The evidence also indicates that the patient's perceptions of the alliance, not the therapist's, predict outcome (Hartley, 1985; Horvath & Greenberg, 1994).
Luborsky's two-component description offers a systematic strategy for building the alliance. The therapist's task in building the perceptual and attitudinal component is to help the patient understand that his or her condition can be treated, that therapy and the therapist are credible, and to encourage the patient to accept help. With the relational component, the task is to establish a collaborative relationship and to help patients recognize and accept this cooperation. Although the perceptual and collaborative components tend to correlate, and many interventions combine both components, the first component tends to emerge earlier in treatment. Note that it is possible to have high levels of trust and positive attitudes without high levels of collaboration.
Building Credibility: The Perceptual and Attitudinal Component
Before they can form an alliance, patients need to believe that both treatment and the therapist are credible and that the therapist is competent and helpful. Therapists can contribute to a sense of optimism and hope on which the alliance is built by behaving, from the outset, in a professional manner that conveys respect, understanding, and support, and by educating patients about their problems and the ways that treatment may help them to reach their goals. Even during assessment, the clinician should be mindful of the importance of fostering hope, given that pretherapy expectations of success are associated with favorable outcomes (Goldstein, 1962; Strupp, 1993). During these initial contacts, hope is conveyed by questions that indicate understanding, and by the therapist's willingness to work with the patient to establish goals and to work on what may seem to the patient to be intractable problems. During the early stages of treatment, exploration of the patient's doubts or reservations about treatment or the therapist's ability to help may preclude premature termination-a major problem in treating patients with personality disorder (Gunderson et al., 1989; Skodal, Buckley, & Charles, 1983; Waldinger & Gunderson, 1984).
The alliance is also built on the rapport created when understanding and acceptance are communicated through careful listening and sensitive responses. Providing regular summaries of the therapist's impressions of the patient's difficulties, beginning with the assessment interviews, also facilitates rapport. These summaries also address fears that the therapist has preconceptions about what is wrong on will not really listen or take the patient's problems seriously.
As noted, realistic goal setting enhances the alliance and the bond between patient and therapist (Borden, 1994) ongoing indications of support for the goals of therapy and a consistent focus on these goals are associated with patients' ratings of progress and the quality of the treatment relationship (Allen, Tarnoff, & Coyne, 1985). Supporting patients' goals occurs through encouraging patients to talk about the importance of their goals and whether they think they are making progress toward achieving them. Reminding patients of their goals on occasion maintains a focus on change and conveys the idea that the patient's beliefs and wants are important.
Ultimately, it is the patient's experience of change that cements the working relationship. Many patients, however, are reluctant to acknowledge their own progress. For this reason, therapists should recognize progress by highlighting even minor changes. Thus, if a goal is to reduce anxiety, occasions when the patient feels that he or she has not overreacted or has managed to contain a sense of panic should be acknowledged and reinforced. The following vignette indicates this process:
A woman in her late 20s, with a long history of psychiatric problems, sought help with relationship difficulties associated with emotional dysregulation (borderline pathology). She was extremely moody, frequently overcome by anxiety and panic, and had uncontrollable angry outbursts. As a result, her relationships were chaotic and volatile. The early treatment sessions were difficult. Extreme affective lability created frequent problems so that treatment was crisis-oriented. It had also been difficult to establish a working relationship. The patient was reluctant to trust the therapist and believe that he was interested in her problems. She constantly accused the therapist of not listening. During the session in question, the patient berated the therapist again for not listening or understanding. She pointed out that it was impossible to work with him when she could not trust him and when she felt that she had to keep him entertained to hold his attention. She maintained that doing so caused an enormous strain for her.
During this barrage, the patient mentioned that she had not consumed any alcohol for a week, and that she had consistently attended AA. The therapist asked her to describe what had happened in the previous week. She said that after the previous session, she had decided not to drink and to attend AA daily. Although the first group that she attended had not been helpful, she had found a second group with which she felt more comfortable. Now she went every evening. The therapist commented that she must be pleased that she had been able to break a habit of 15 years' duration and had been able to go for 7 days without a drink. Somewhat reluctantly, the patient acknowledged that she was pleased. The therapist then went on to note that, although she was describing major problems in therapy, it also appeared that the therapy was helping. Again, the patient reluctantly acknowledged that this was the case, and they began a discussion of the way therapy had been helpful. During the discussion the patient noted that perhaps the therapist was listening, and may even know what he was doing, and that she was benefiting from treatment.
This episode indicates that building the alliance does not require major interpretations. In this case, recognition of progress was sufficient. Explicit acknowledgment of progress need not await major changes. Instead, it is useful to acknowledge small changes early in treatment, as illustrated by the following vignette.
A fairly withdrawn man with inhibited or schizoid-avoidant traits had attended twice-weekly treatment for about 6 weeks. The early sessions were dominated by his feelings of hopelessness and despondency stemming from negative thoughts about all aspects of his life, and considerable anxiety, uncertainty, and pessimism about the future. His overriding conviction was that that he was a failure. Nothing he tried ever worked out, and he saw few prospects for change.
After being in treatment for about 3 months he took up a sport that had appealed to him for some time, and a few days later he began to pursue an artistic interest. During one session, he commented that things had gone well for him during the previous week, and that he had begun thinking about the future, especially about a career. This had been an unresolved issue for many years, but now several interesting possibilities were raised. Furthermore, these issues were discussed in a more positive and less anxious manner than previously. The therapist noted that he seemed to be feeling a little differently about things. The patient responded by saying that he was now enjoying sports, music, and other activities. The therapist commented that several things appeared to have changed over the last few weeks.
Excerpted from Practical Management of Personality Disorder by W. John Livesley Copyright © 2003 by The Guilford Press. Excerpted by permission.
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