Approach to Treatment of Patients With Personality Disorders

Approach to Treatment of Patients With Personality Disorders

An Integrated Approach to Treatment of Patients With Personality Disorders

John F. Clarkin Weill Cornell Medical College

Nicole Cain Long Island University

W. John Livesley University of British Columbia

We describe a framework for the application of treatment modules to the major domains of dysfunction manifested by clients with personality disorder. This integrated approach takes the clinician beyond the existing limited treatment research by using strategies and techniques from all the major treatment schools and orientations. This effort is necessary and timely because the field of personality disorders is currently struggling to further define and understand personality pathology beyond categories by articulating major dimensions of dysfunction across the personality disorder types marked by various degrees of severity.

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Keywords: personality disorders, psychotherapy, psychotherapy integration

Personality disorders (PDs) are prevalent and debilitating and have a powerful negative im- pact on work functioning and intimate and in- terpersonal relations. There are many impedi- ments to the treatment of patients with personality pathology, including controversies in defining PD, the rampant comorbidity among PDs and with symptom disorders, the range of severity across the disorders, the difficulties in identifying the key dimensions of personality dysfunction, and the paucity of treatment re- search on the numerous PD types.

In this article, we articulate an integrated modular approach to the treatment of PDs. We describe a framework for the application of treatment modules to the major domains of dys- function manifested by clients with PD. This is called an integrated approach (Stricker, 2010; Norcross & Wampold, 2011), because it takes the clinician beyond the existing treatment research—which is limited—and uses strategies and techniques from all the major treatment schools and orientations. An integrated modular approach emphasizes:

(a) the individuality of the patient, and not the category of disorder,

(b) the domains of dysfunction in the individual patient,

(c) the therapeutic use of modules of intervention from existing clinical approaches, especially those that have been empirically investigated, and

(d) the construction of a smooth fabric of intervention in the context of a developing alliance between therapist and patient.

Our attempt here and elsewhere (Livesley, Dimaggio, & Clarkin, in press) is to further the effort at integration by articulating a treatment framework specifically for those individuals with PDs. This effort is necessary because the field of PDs is currently struggling to further define and understand personality pathology be- yond categories by articulating major dimen- sions of dysfunction across the PD types marked by various degrees of severity (Clarkin, 2013).

There is an emerging consensus that the es- sence of the PDs across the various categorical types centers on difficulties in self-functioning and interpersonal functioning (Sanislow et al., 2010). The product of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi- tion (DSM-5) Personality Disorder Work

John F. Clarkin, Department of Psychiatry, Weill Cornell Medical College; Nicole Cain, Department of Psychology, Long Island University; W. John Livesley, Department of Psychiatry, University of British Columbia.

Correspondence concerning this article should be ad- dressed to John F. Clarkin, New York Presbyterian Hospi- tal, Weill Cornell Medical Center—Westchester Division, 21 Bloomingdale Road, White Plains, NY 10605. E-mail:

Journal of Psychotherapy Integration © 2015 American Psychological Association 2015, Vol. 25, No. 1, 3–12 1053-0479/15/$12.00

Group—located in Section III of DSM-5 (2013)—provides a potential correction to the previously predominant focus on symptoms, be- cause it brings the field back to focus on the essence of personality pathology that is self and interpersonal functioning. Approach to Treatment of Patients With Personality Disorders

Why Consider an Integrated Approach to Treatment?

Evidence-based practice is defined as the combination of best available research with clinical expertise in the context of patient char- acteristics, culture, and preferences. There is every cogent reason to use information from empirically supported treatments when avail- able, but in reference to the PDs, the treatment research is limited to a few disorders, and even with those disorders, the results tend to be com- parable across treatment packages. Evidence- based practice for PDs must contend with a number of limitations in the research literature, and use clinical expertise to match the individ- ual client with the best treatment approaches.

The difficulties with applying the empirically supported treatment approach to the PDs are numerous. For example, PDs are marked by heterogeneity both within diagnosis and with comorbidity across the PDs. The various constellations that PD assumes make it difficult to articulate a treatment that fits all individuals even within one PD category. In addition, psychotherapy research to date is limited to a few disorders with relatively comparable effects. Only a few of the 10 DSM PDs have attracted psychotherapy research, with the vast majority of treatment research focused on borderline personality disorder (BPD). There is no indication that each disorder will be investigated with treatment research, but the clinician must proceed despite this situation.

There is also a growing awareness that genes and neurocognitive dysfunction are not specific to a particular diagnostic category, but rather are functions across diagnostic categories that are potential foci for therapeutic intervention. Molecular genetics will not provide a simple, gene-based classification of psychiatric illnesses, but rather genetic findings will likely delineate specific biological pathways and do- mains of psychopathology (Craddock, 2013). In this regard, the National Institute of Mental Health has declared an initiative to focus research not on categories of mental illness but on systems of neurocognitive functioning and dysfunction that extend across diagnostic categories (Hyman, 2011).

Finally, medicine in general is advancing to- ward an individualized approach to both assessment and treatment. Each individual is biologically unique, and this uniqueness suggests that treatment should be tailored to the individual. Although there are commonalities across people at the psychological level of functioning, it has become evident that each individual has a unique psychological history of development and engagement in the environment (Norcross & Wampold, 2011). This uniqueness is the fo- cus of the clinicians’ assessment of clients with suspected PD, the results of which guide the tailored intervention with that client.

With these issues in mind, we are recommending an integrated treatment approach that is probably already the most popular approach to the treatment of clients with PDs. We think it remains important to describe an integrated approach to the treatment of PDs in order to further clarify the issues and refine the approach. An articulation of an integrated approach to treatment may also legitimize the wise integrative approaches of many clinicians who worry that they are violating the empirical treatment recommendations. Approach to Treatment of Patients With Personality Disorders

What Is Integration?

We regard integration as a mental process engaged in by the clinician. This process begins at the first meeting between therapist and patient. The focus of the integration is the individual patient with a PD who is seeking help. The content of integration is the unique combination of domains of dysfunction matched with modules of intervention that are applied in a particular sequence over time.

In this conception of integration, one can conceive of a number of steps in this process: (a) arriving at a working conception of the patients’ dysfunctional domains, (b) generating a vision of how the client could realistically achieve a better level of adjustment, (c) imagining how this client can improve over time in a stepwise, progressive pattern, (d) using therapeutic interventions timed to the client’s readiness to change and salient problems at the moment, and (e) therapist awareness throughout treatment of the client’s perception of him or her and the impact on the process of change. The process of integration as conceptualized here is quite consistent with the empirically supported treatment approach mentioned be- fore. In the absence of empirical evidence for specific treatments for each of the PDs, and in the absence of empirical information on mechanisms of change, the clinician is forced to use his or her clinical judgment moment-to-moment and across a treatment episode.

Probably the most salient exception to the dearth of empirically supported treatments for PDs is the treatment evidence for BPD. Cognitive–behavioral (Linehan, 1993), mentalization-based (Bateman & Fonagy, 2006), and object relations treatment (Clarkin, Yeomans, & Kernberg, 2006) are all empirically supported. Although we know that these treatment packages are associated with symptom change, there is little clarity about which elements in each approach are effective. In addition, some clients do not respond to the particular approach. It is possible that a more tailored approach to the particular patient with his or her unique strengths, weaknesses, and environment may produce significant change.

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