Goals of Treatment

Research findings suggest that many forms of treatment of personality disorders can be equally effective. The guiding principle is the recognition of a personality disorder as being chronic and as defining the essence of the individual. The aim of treatment then is not to cure but rather to reduce distress and improve function. Livesley (2004) has proposed four principles as inherent to personality disorders, each of which needs to be considered in the treatment plan:

1. A personality disorder is central and involves all aspects of the personality structure. Therefore, an effective treatment plan must incorporate a range of interventions and not just be a response to a specific problem. An implication of this is that the treatment indicated is typically long-term rather than brief.

2. There exist core features common to all personality disorders and other features common to specific personality disorders. Therefore, treatment needs to incorporate strategies to manage the personality disorder as a general psycho-pathology and to offer customized strategies to address the more specific and idiosyncratic manifestations of specific personality disorders.

3. A personality disorder reflects a biopsychosocial etiology. Therefore, interventions need to reflect multiple contributing factors, with the overarching goals of reducing distress and facilitating adaptation and functionality.

4. Adventitious stressors ("psychosocial adversity";p. 574) impact the personality system and those with personality disorders are especially vulnerable. Therefore, the treatment also needs to address the consequences of these particular stressors. Recall that exaggerated responses to stressors are pathognomic of a personality disorder.

Therapy needs to be reasonable, realistic, and practical (Paris, 2003). What is reasonable and what is not? The individual cannot be recreated or reinvented. His life story cannot be rewritten, and his defensive structure should not be dismantled. This is not because it cannot be done, but because dismantling implies the possibility of him being left without defenses (maladaptive or otherwise), being defenseless, at a stage in life where he may not have the necessary self-resources or time to allow a reconstruction of character. The process of treatment includes assessing the personality traits of the individual, and identifying which are adaptive and which are maladaptive, with the referent(s) of both being clearly identified. These referents elucidate the specific threats and challenges the individual faces, how they are met by his personality traits, and how they may directly contribute to the distress he experiences. These referents can be at the level of the context or system (e.g., when the individual is a patient in a hospital), the level of a group (e.g., a member of a senior center or a family), or the level of a dyad (e.g., in relationship with a spouse or child).

The referent can also refer to a specific task required of the individual for him or her to be appraised as functioning acceptably or adaptively. For example, an individual moving into an assisted living facility after living independently in her own home is now required to regularly participate in a residents' group, where she is expected to voice her concerns and complaints. If she has an Avoidant Personality Disorder, this could be painfully difficult for her. Another example might be a man with Schizoid Personality Disorder who must share a room with other men in a rehabilitation facility. He would likely feel highly anxious with this degree of unfamiliar intimacy and infringement on his personal space. This could be acted out in ways that would interfere with the tasks involved in his rehabilitation program (e.g., refusing group activities or even leaving the program prematurely).

Therapy needs to also identify and address which characteristics or traits of the individual might be adaptive to his current circumstances, and include these in the treatment plan. In other words, it is important to put adaptive traits to use. Doing so serves several functions. Using "adaptive" traits (i.e., giving them a job) reduces the expression of less desirable traits, respecting the concept of reciprocal inhibition. It is always useful to reinforce healthy narcissism, in other words, to make certain the individual has an opportunity to express and is rewarded for expressing that which he most values in himself. Enhancing the positive (or nonmaladaptive) traits increases the probability that the individual will receive positive rather than negative feedback from the environment. It also reduces the strength of the stressor and thereby reduces the challenge to the individual's resiliency.

Any treatment should of necessity be a combination of approaches and strategies to best address the individual's symptoms, her relationship with others, and the context of care. Treatment needs to be clearly relevant to what the individual understands as having a negative impact on her life. If the individual does not understand the relationship between this distress and the treatment offered, she will not sign up for the treatment, or she will sabotage it.

Treatment needs to respect both internal and external individual resources. Internal resources may include time, interest, energy, and money. External resources may include the support and encouragement offered by others. Treatment must appear to be wise to the individual—operationalized as concrete, appropriate, and doable. It also needs to appear to have a low requirement for change and a high probability of achieving the desired results.

Treatment must be perceived as being moderately novel: It must fall somewhere between the appraisal that "I've tried it and it doesn't work" and "This is too strange. It doesn't feel at all comfortable to me." Treatment above all must be seen as being worth the effort to make the required change. The clinician should be aware that change is difficult for people in general and that change may be particularly hard for personality disordered older adults who have used their rigid approach to coping and problem solving for many years, so helping the patient see the potential benefit to change is important. And the benefit must be to the patient, and not merely to other's in the patient's life.

What ( Little) Is Known 275

Personality disorders are often omitted from a diagnostic formulation, and therefore are not addressed in a treatment plan. There are several ways to understand this omission. There is the assumption that an Axis II disorder is not treatable because it describes the pathology of the individual's characterological infrastructure, which, it is assumed, cannot be significantly altered.

Personality disorder diagnoses are often used as pejorative labels, which serve to close off treatment options. For example, the label "Borderline" is frequently clinical shorthand for a potpourri of negative countertransference reactions to the patient's manipulative and rageful tendencies and noncompliance with treatment.

There are also fiscal disincentives to treating Axis II conditions. Many managed care products discourage what might be lengthy and difficult treatments in favor of highly specific foci for short term treatments. The individual with a personality disorder diagnosis or diagnoses, in the absence of a diagnosable Axis I condition, can be disallowed authorization for more than minimal treatment.

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