Family Treatment of Personality Disorders

Advances in Clinical Practice

Malcolm M Macfarlane

• Publisher: Routledge
• Year: 2014
• Print ISBN:
  9780789017901
• eBook ISBN:
  9781317787846
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Help families cope with the impact of personality dysfunction!

Family Treatment of Personality Disorders: Advances in Clinical Practice examines the application of marital and family therapy approaches to the treatment of a wide range of personality disorders. Valuable on its own and doubly useful as a companion volume to Family Therapy and Mental Health: Innovations in Theory and Practice (Haworth), the book integrates traditional individual models with family systems models to provide a multidimensional approach to treating personality disorders. Each chapter is written by a family therapist with extensive experience treating personality disorders and includes a case example, an exploration of the impact of the disorder on family members, a look at cultural and gender issues, and an examination of how the model is integrated with traditional psychiatric services and the proper application of medication.

Family Treatment of Personality Disorders is a single, accessible source for significant contributions to the emerging literature on family treatment approaches that, until now, have been scattered through journals representing a variety of disciplines. The book's strong clinical focus provides a concise summary of relevant theory and interventions for effective treatment, including discussion of how to manage crises and acting out behavior. Edited by a practicing frontline clinician, the book provides an overview of the personality disorders field, examines the Structural Analysis of Social Behavior model and the Interpersonal Reconstructive Therapy approach, and presents detailed descriptions of key concepts and treatment approaches.

Family Treatment of Personality Disorders focuses on specific DSM-IV personality disorders, including:

• borderline
• narcissistic
• histrionic
• obsessive-compulsive
• passive-aggressive
• avoidant
• dependent
• paranoid

Family Treatment of Personality Disorders: Advances in Clinical Practice is an excellent resource for clinicians treating mental health problems and for academic work in family psychopathology and family therapy and mental health.

PART I:
OVERVIEW

Chapter 1

Family Treatment of Personality Disorders: Historical Overview and Current Perspectives

Jeffrey J. Magnavita
Malcolm M. MacFarlane

INTRODUCTION

Since the inclusion of a separate Axis II category for personality disorders in the third edition of the American Psychiatric Association’s (1980) Diagnostic and Statistical Manual of Mental Disorders (DSM-III), interest has burgeoned in the field of personality disorders, resulting in an explosion of texts and journal articles regarding the etiology and treatment of personality disorders (Magnavita, 1998b). Tremendous development has also occurred in the areas of personality theory and models of treatment, with the result that many personality disorders that were previously regarded as untreatable are now considered amenable to therapeutic intervention (Sperry, 1995).

Many reasons may account for this fascination with personality disorders. Perhaps a part of the fascination is that we all have personalities, and the desire to know and understand what goes awry in individuals who develop personality disorders is central to understanding our own potentials and vulnerabilities. On a more pragmatic level, however, is the reality that personality disorders are extremely pervasive, particularly among clinical populations, and their presence tends to complicate routine treatment for relationship problems and Axis I disorders, such as anxiety, depression, and other clinical syndromes. Most clinicians have had the experience of setting out to treat what seems to be a routine case of depression or a straightforward marital issue, only to find their treatment plan thwarted by entrenched personality characteristics that interfere with the change process. An ability to understand and treat personality disorders effectively is an essential skill for any clinician.

Until recently, individual models for understanding and treating personality disorders have tended to dominate the field. Where family factors have been explored at all, the focus has often been on family variables contributing to the development of psychopathology, rather than on the impact of personality disorders on the family, or on ways the family can aid and enhance effective treatment. This lack of attention to the interpersonal and family impact of personality disorders is strange, since the first three diagnostic criteria for personality disorders outlined in the fourth edition of the DSM (American Psychiatric Association, 1994) clearly target interpersonal aspects. Criterion A includes “interpersonal functioning” as an area in which the personality disorder may be manifested in which criterion B requires that the disorder be pervasive “across a broad range of personal and social situations,” and criterion C requires that it lead to distress or impairment in “social, occupational, or other important areas of functioning” (p. 630, reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, copyright 1994 American Psychiatric Association).

Although individually focused psychodynamic and cognitive behavioral models provide useful insights, the lack of a systematic framework for understanding how individual personality traits are enacted in significant interpersonal relationship contexts can leave clinicians floundering. A major need exists for integrative multidimensional models for working with personality disorders that blend individual and family systems treatment approaches. As MacFarlane (2001, p. xxii) states, “It is time for family therapy approaches to be more integrated into the mental health field.”

This book attempts to provide mental health clinicians with an integrative framework for understanding personality disorders in a relationship context. The text explores a variety of integrative multidimensional models and approaches for intervening in marital, family, and interpersonal systems to bring about change in the personality-disordered individual, and aid families in coping with the impact of personality-disordered family members. To provide a context for the chapters to come, however, it may be helpful to have a better understanding of historical and current perspectives regarding personality disorders.

WHAT ARE PERSONALITY DISORDERS?

Personality disorders (PDs) are best conceptualized as a dysfunction in the personality system of an individual, their relational matrix, and total ecosystem, that can manifest themselves in a variety of ways, but are most clearly characterized by patterns of relationships and behavior that are repetitive and tend to be maladaptive to the individual’s sociocultural setting (Magnavita, in press). The relational matrix broadly includes the internalization of relationships by an individual on an intrapsychic level (e.g., object relations, schematic representations—relational or cognitive schema), dyadic configurations (e.g., couples, parent-child subsystems), triangular relationships (e.g., parent/parent/child triangle, partner/partner/lover triangle), family systems (e.g., dysfunctional personologic systems), and social institutions (e.g., school systems, religious institutions, prisons). The relational matrix also includes the relational components of the therapist and patient, which is the primary foundation on which psychotherapy rests. These are often referred to in the literature as “common factors” (Norcross and Goldfried, 1992).

The maladaptive patterns can include various domains from the biopsychosocial matrix, such as affective regulation, cognitive-perceptual distortion, interpersonal disturbance, behavioral inappropriateness, and impulse control management. The personality “system” of the individual needs to be considered in totality, emphasizing the interrelationships among the components of the biopsychosocial model in the relational field (Magnavita, 2000c).

PERSONALITY DISORDER CLASSIFICATIONS

DSM Definition—Current Categories and Clusters of Personality Disorder Types

The most widely used classification system for personality disorders is the categorical model of the DSM, which has numerous editions (American Psychiatric Association, 1994). The current multiaxial system, whereby five separate axes are used, was an important advance for the study of personality because personality disorders were given their own separate or Axis II classification, differentiating them from the Axis I clinical syndromes (Magnavita, 1998a). This led to an increase in the research and development of new treatments for these disorders, which previously had been considered untreatable, with the exception of long-term psychoanalysis, which itself had questionable results. The DSM classification system gave researchers a criteria-based method for establishing the presence or absence of a personality disorder.

The DSM (APA, 1994, p. 629) defines personality disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, copyright 1994 American Psychiatric Association). The DSM divides personality disorders into three clusters:

1. Cluster A, characterized by odd or eccentric behavior, includes paranoid, schizoid, and schizotypal personalities. This cluster is considered the most treatment refractory, and is probably the most likely to have strong genetic predisposing factors. Longer-term treatment combined with pharmacotherapy is often required.

2. Cluster B, characterized by erratic, emotional and dramatic presentation, includes antisocial, borderline, histrionic, and narcissistic personalities. This cluster includes what are considered the more severe personality disorders with mixed treatment outcome. A number of newer treatment models, primarily psychodynamic (Clarkin, Yeomans, and Kernberg, 1999) and cognitive-behavioral (Linehan, 1993) have been developed.

3. Cluster C, characterized by anxiety and fearfulness, includes avoidant, dependent, and obsessive-compulsive personalities. These disorders are considered the most responsive, and have shown good results with short-term dynamic psychotherapy (Winston et al., 1994) and cognitive therapy (Beck, Freeman, and Associates, 1990).

Complex and Overlapping Personality Disorders

In addition to the personality disorders and clusters described earlier, the DSM-IV also provides a category called “Personality Disorder Not Otherwise Specified” (NOS). This category is intended to be used for disorders of personality functioning that do not meet criteria for any specific personality disorder, or where the features of several personality disorders do not meet the full criteria for any one category. This category may also be used for specific disorders that are not included in the DSM, such as depressive personality disorder or passive-aggressive personality disorder.

Problems with the DSM Categorical System

Problems with the DSM system of classification should be mentioned. Researchers have found a high incidence of overlap categories, with most patients receiving multiple diagnoses. This problem underscores a lack of precision that may ultimately affect the utility of this categorical system. Another criticism is the system’s lack of sensitivity to subsyndromal variations which might have an important bearing on treatment. For example, when a patient does not meet the full criteria for an Axis II diagnosis, provisions are not made for personality attributes that fall below the diagnostic threshold even when they have significant impact on treatment. An individual with major clinical depression, for example, may have strong passive-aggressive or narcissistic traits that make noncompliance with medication and psychotherapy likely.

Some clinicians and researchers have suggested that the difficulty with the DSM categorical systems lies in the descriptive nature of this system and its focus on clinical syndromes. They criticize the system for its lack of a consistent theoretical basis for understanding and accounting for the etiology of these disorders, and its lack of clinical relevance in terms of treatment planning. They also question the basic assumption underlying categorical systems or typologies, which is that personality disorders are discontinuous, or separate and distinct from the normal range of personality development rather than an outgrowth of normal personality characteristics (Livesley et al., 1994; Widiger and Sanderson, 1995).

Other Systems of Classification

Other diagnostic systems of classification offer different and useful perspectives, but also have limitations and disadvantages. Unfortunately, a full exploration of the merits and difficulties of these systems is beyond the focus of this chapter. Four additional systems of classification include: dimensional, prototypical, structural dynamic, and relational classification.

Dimensional Classification

Dimensional classification systems are based on the premise that personality disorders are not discontinuous with normal personality development, but in fact are part of a continuum of normal personality traits. Costa and McCrae (1992), for instance, outline what has come to be called the “five-factor model.” This model identifies five core personality dimensions: neuroticism, extraversion, openness, agreeableness, and conscientiousness.

Proponents of dimensional classification systems suggest that personality disorders represent extreme and maladaptive versions of one or more normal personality traits or combinations of traits (Livesley, 1998). Personality pathology is placed on a continuum, and cutoff points are established empirically. This method of classifying personality is useful in that it enables clinicians and researchers to identify threshold and subsyndromal variations of personality disorder, as well as normal traits which, when the individual is under stress, may exacerbate behavior or symptoms.

Prototypical Classification

The prototypical classification system developed by Millon and Davis (1996b) attempts to combine both the qualitative distinctions of the DSM categorical system with the quantitative strengths of the dimensional system. The authors suggest the clinician ask both “how” and “how much” the client resembles the prototypical patient with a particular disorder. One of the advantages of this type of system is that it does not sacrifice sensitivity to the subsyndromal variations mentioned earlier.

Structural Dynamic Classification

This system is based on psychoanalytic character types and arranges personality on a structural continuum: normal, neurotic, borderline, and psychotic (Kernberg, 1984; McWilliams, 1994). Kernberg’s structural-characterological system is quite useful for conceptualizing personality organization and structure. Many clinicians find Kernberg’s system more clinically useful than the categorical system. In Kernberg’s conceptual model, borderline is not a separate category, but refers to the level of ego organization, structural integrity, and ego-adaptive capacity that exists on the continuum from normal to psychotic. Each personality type, such as hysterical, obsessive, depressive, passive-aggressive, and so forth, can be organized at the various levels of the continuum. This diagnostic system informs treatment by allowing the clinician to differentiate, for example, between two obsessive characters, one functioning near the borderline level and the other near the neurotic. The obsessive with borderline organization is going to be more challenging in treatment due to fluctuations in ego-adaptive capacity.

Relational Classification

Relational classification has its roots in the systemic model (Ackerman, 1957, 1958) in that it views personality as existing within a complex biopsychosocial system, not just within the individual. This interpersonal matrix includes both dyadic (Sullivan, 1953) and triadic configurations (Bowen, 1976). Relational diagnosis was advanced by Kaslow (1996) and applied to dysfunctional personologic systems (Magnavita, 2000c). Magnavita’s approach attempts to classify the variety of dysfunctional personologic systems that spawn personality disorders, and that often result in multigenerational transmission. One of the advantages of relational classification systems is that they serve to orient the clinician to the impact personality disorders have on significant interpersonal relationships and family members.

A Multisystem Diagnostic Assessment

Perhaps the most useful way to approach diagnosis is to use a multiperspective that eschews a narrowband formulation and classification based on limited clinical data. “Comprehensive assessment utilizes various systems, placing them in the relational matrix to provide a broader perspective” (Magnavita, 2000c, p. 95). In this manner the diagnostician-clinician uses the multiple lenses of the various systems presented earlier without relying exclusively on any one system to construct the clinical holograph of the patient’s personality system (Magnavita, in press).

PREVALENCE AND COMORBIDITY

Relatively few studies have documented the prevalence of personality disorders. According to Mattia and Zimmerman (2001), “Due to the relative paucity of national efforts, the epidemiology of personality disorders in the general population is a difficult issue about which to draw firm conclusions” (p. 120). The most widely cited study by Merikangas and Weissman (1986) found that the prevalence of personality disorders in the general population is about one out of ten. More important, they also revealed that about half of those who seek mental health treatment are diagnosed with a personality disorder. Given these findings we can anticipate that those in clinical practice may expec...

Table of contents

• Cover Page
• Half Title page
• Series Page
• Title Page
• Copyright Page
• Contents
• About The Editor
• Contributors
• Foreword
• Preface
• Acknowledgments
• Part I: Overview
• Part 2 Specific Disorders
• Name Index
• Subject Index