Expert accounts of personality disorder have tended
to group around certain leading scholars or research teams, each existing with
what has appeared to be only coincidental overlap in terms of theoretical and
conceptual preferences, and minimal collaboration in terms of publishing.
Important contributions to the discourse by one team might thus not cite the
work of other teams. It is natural to invoke disciplinary territorialism as one
reason for this, leavened by at least a pinch of academic, institutional and
even international rivalry, and compounded by the preference of some groups for
focusing exclusively on 'personality disorder', and of others on 'psychopathy',
as if they were mutually exclusive. Of course, personality disorder and
psychopathy are not the same thing, but there is sufficient overlap, and what
we might call 'interpenetration' of themes, as they relate to forensic contexts
for example, for work in relation to one concept to have relevance for the
other.
W. John Livesley is a psychiatrist
whose research has been directed at the classification and etiology of
personality disorder, and this book is the result of a natural progression to
addressing the question of its management. It is significant that Livesley is
based in British Columbia, because it is also home to R.D. Hare and his
colleague Stephen Hart, who are psychologists, and world-renowned experts on
psychopathy. Livesley mentions psychopathic personality only briefly, and
chooses not to engage with their work, or with that of Marnie Rice, Grant
Harris, Vernon Quinsey and their colleagues in Ontario, all internationally recognized
for their work on psychopathy. He begins by acknowledging that a comprehensive
theoretical account of the disordered personality is not available, and that
the focus must therefore be on personality problems and pathology. Livesley
adopts an eclectic approach to personality, influenced by psychoanalytic, ABC,
five-factor, and the subsequent four- factor, theories. Personality is also
conceived as a response to the tasks of daily living, a view Livesley traces
back to Allport, and supports with research evidence. Personality disorder is
described as a failure to achieve adaptive solutions to life tasks, and domains
of consequent psychopathology suggested as coextensive with DSM-IV
diagnostic criteria. The explicit consequence of this account is that treatment
is eclectic and must be aimed at improving adaptation.
Chapter three provides an overview
of aetiology, with detailed sections on psychosocial and genetic factors. The
lesson Livesley takes from this review is that the goal of treatment should not
be to change personality traits but to help individuals express their traits
more constructively. He also addresses the issue of stability, which he
believes is widely neglected but critical to this goal.
He describes alternative behaviors,
and obstacles to their realization. Although supported by references to the
research, the chapter on assessment and diagnosis is exclusively descriptive
and clinical, and largely ignores standardized tests. Whilst committed to
evidence based practice, Livesley acknowledges the current inadequacy and equivocality
of the evidence as it concerns the management of personality disorder. He
emphasizes a treatment milieu which is supportive, empathic, validating and,
above all, collaborative. A chapter is devoted to treatment planning and the
formulation of a treatment contract, subsuming a practical step-by-step guide,
and laying the foundations for the next chapter, on therapeutic strategies
which aim to promote collaboration, consistency, validation, and motivation. He
moves on to the treatment of clinical symptoms and crises, which are described
in cognitive-behavioral terms, and then details a range of practical
strategies, emphasizing the need for containment and control, and detailing the
rationale and indications for medication and in-patient treatment. He goes on
to overview and recommend interventions -- mostly of a cognitive-behavioral and
psychotherapeutic nature -- for: disordered affect and impulses, notably
self-harm and dysphoria; dissociative and post-traumatic behavior; the self,
and interpersonal problems; and, maladaptive traits, such as recklessness,
callousness and narcissism, a subject on which Livesley has already copiously
published. He concludes with a discussion of the prospects for treating 'core
pathology', drawing on concepts such as self-state sensitivity, and self-theory
reconstruction and integration.
There are a few topics which might
have been expected to be discussed and are hard to locate anywhere in the text,
such as standardized tests and actuarial risk assessment; antisocial personality
disorder and the linkages with psychopathy receive short-shrift; and, it is not
an easy text to navigate. However, Livesley provides a wealth of apposite case
illustrations, helpful tables and diagrams summarizing frameworks and schema,
and italicized key points or principles. He is eclectic, evidence-based
wherever evidence is available, and logical and persuasive where it is not, and
I believe clinicians will only rarely disagree or find his recommendations
problematic.
This is a major work of reference
for mental health clinicians of all disciplines and, along with Millon et al.'s
recent Personality Disorders in Modern Life, is genuinely indispensable
to those who are faced with the complex and challenging task of providing
treatment, in whatever setting, to people with disordered personalities.
© 2005 Colin A Holmes
Dr Colin A
Holmes, Professor, School of Nursing Sciences, James Cook University, Townsville,
Queensland, Australia
