Psychological Treatments

Few studies have addressed the efficacy of psychological treatment where personality disorder pathology is the main focus, and fewer still have included significant numbers of older adults in the samples. Most often studies have focused on personality disorder with a comorbid Axis I condition, using mixed ages with older adults underrepresented or not represented at all. There are a number of ways this can be understood. Younger adults with a personality disorder are typically more florid and more acute in their presentation; they present for mental health treatment more readily than older adults; they do not have the medical confounds that older adults present in terms of multiple medical conditions, taking multiple medications, and thus are "cleaner" subjects to study. In the following sections we describe several popular psychotherapeutic approaches to personality disorders and identify challenges with older adult patients.

Psychodynamic Psychotherapy

Long-term psychodynamic psychotherapy has historically been the mainstay treatment for the more severe personality disorders, with poor response overall. This has not been shown to be especially effective in the treatment of personality disorders. Many individuals with a personality disorder are not able to tolerate the intervention mainstays of analytically based treatments. For example, confrontation and interpretation could be experienced as a paranoid threat by those in Cluster A, as a threat of narcissistic injury or of abandonment for those in Cluster B, or as intimating rejection and withdrawal of support for those in Cluster C.

In general, those older adults with a personality disorder are also not well suited to the stage-appropriate tasks of life review and self-reflection (Solomon, Falette, & Stevens, 1982). They have great difficulty identifying or tolerating affect; they are prone to acting it out or in rather than being able to bring affect to conscious awareness and to consider it objectively. Also, the individual often has had a long history replete with failure and conflict, so encouraging a deep and meaningful review may be harmful rather than helpful.

Cognitive-Behavioral Psychotherapy

Cognitive-behavioral therapy perhaps is the most appropriate treatment for older adults with personality disorders (Goisman, 1999). Primarily, this is because it does not target the characterological infrastructure but rather focuses on the symptoms and goals jointly arrived at by patient and clini cian. The cognitive aspect can help the individual get past a fixed, egocentric point of view, thereby enabling an expanded repertoire of behavioral options (DeLeo et al., 1999). For this to occur, a therapeutic alliance, which is often an elusive goal with this population, needs to be established. The probability of it being successfully achieved, among other factors, relates to the agreement on therapy goals and acceptance of a partnership (working alliance) to meet those goals. Patient strengths are identified and used to effect positive change. Cognitive-behavioral therapy techniques have been shown to be effective in the treatment of anxiety, depression, impulsivity, aggression, and affective lability conditions and behaviors, which often accompany the personality disorder.

Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT) is a directive treatment model that uses dynamic, cognitive, and behavioral techniques to modify maladaptive relationship patterns. Interpersonal Psychotherapy was developed as a short-term treatment model for depression, and has been shown to be effective with this clinical population. The model has recently been adapted specifically for older adults (see Hin-richsen & Clougherty, 2006). However, it has not been studied as a treatment modality for older adults with a personality disorder, with or without comorbid depression. One study reported on an adaptation of IPT for use with young adults with Borderline Personality Disorder, which suggested some success (Weissman, Markowitz, & Klerman, 2000). The focus with IPT is on the interpersonal context, at the juncture at which most problems (and stress) occur; this is especially problematic for the individual with a personality disorder. The adaptation for use with Borderline Personality Disorder adds to the original protocol an additional focus on self-image.

284 Chapter 10 Treatment: General Issues and Models Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) has received considerable attention and has been shown to be an effective treatment for personality disorder, specifically for Borderline Personality Disorder (for a thorough review, see Robins & Chapman, 2004; also Scheel, 2000). Its efficacy with older adults is beginning to get research attention. Dialectical behavior therapy is a cognitive-behavioral treatment model based on biosocial theory with the premise that personality disorder symptoms reflect biological irregularities (Shearin & Linehan, 1994). The treatment is multi-focused and uses individual and group modalities. Dialectical behavior therapy incorporates problem-solving strategies, stress reduction techniques, and attention to the relationship between the individual and the environment.

The DBT model teaches and coaches problem-focused techniques and includes skills training for the purposes of reducing or eliminating maladaptive responses and replacing them with more adaptive responses. Boundaries, including clinical boundaries, are clearly delineated and protected. The training is hierarchical and progressive, consistent with behavioral models in general.

As noted, most of the DBT studies have focused on younger personality disorder populations. Ongoing research studies (Lynch, Morse, Mendelson, & Rubins, 2003) are evaluating the efficacy of DBT with older adults with a personality disorder and comorbid depression. Findings to date have shown DBT to be more effective than treatment as usual, typically pharmacological treatment, in a number of ways including improvement in adaptive coping, decreased reactivity, decreased self-critical behavior, and decreased feelings of hopelessness. Dialectical behavior therapy is a skills-based approach, and as such, there is no reason to think it should not apply well to older adults.

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