Psychotherapy for Personality Disorders is a slim volume
put out by the American Psychiatric Press as part of its Review
of Psychiatry series. At first glance is seems too slim,
given the amount that has been written about the treatment of
these disorders. In professional books, I tend to look for the
thick ones, assuming (immodestly) that for me to learn something
new takes a lot more words. However, this book is a pleasant
(and educational surprise).
The book is comprised of five chapters on different topics.
Of these, I was most impressed with the first three. Chapter
One focuses on the empirical studies of psychotherapy for personality
disorders. It reviews the literature addressing several critical
questions, including: (1) Does psychotherapy result in significant
improvement? (2) Do some diagnoses respond to treatment better
than others? (3) What changes occur during and after psychotherapy?
The author's conclusions are hopeful-yes, psychotherapy works,
to oversimplify. They also provide an object lesson to those
who would like to advance the field. This lesson is that our
research on treatment is inadequate in both quality and quantity.
Chapter Two focuses on psychotherapy for borderline personality
disorder. Gunderson provides a thoughtful review of the treatment
of these patients. He reviews the characteristics of both patient
and therapist that contribute to the success of therapy, discusses
the therapeutic alliance and outlines various phases of the treatment
across time. I especially appreciated Gunderson's use of tables
to summarize key points. His making a distinction between therapy
and case management made me rethink the nature of the care I provide
in treatment. Borderline patients are among the most challenging
for therapists and access to a review such as this may be used
by an experienced therapist who needs to reconsider his or her
management of a difficult patient or by a trainee who is encountering
such patients for the first time.
In Chapter Three, Glen Gabbard provides a similarly fine review
of the issues related to combining medication with psychotherapy.
As he points out, when treating personality disordered patients,
the psychiatrist has to be constantly mindful of what he is prescribing
and why. His approach to breaking down the reasoning behind prescribing
to the personality disordered individual and reference to the
literature to support such use is quite helpful.
I was less content with the final two chapters. The chapter
on antisocial personality disorder did a nice job of breaking
down this disorder into components related to treatability, but
did little to encourage one to take on such a patient. Whereas
the tone of the previous chapters was to educate the reader on
how to treat, this chapter focused on who to treat. This is likely
due to the limitations of the field, but the overall message is
except for mild cases, don't bother.
Likewise, the final chapter could have been better developed
and was not up to the promise of the first three chapters. It
did not do justice to the promise of cognitive therapy in the
treatment of personality disorders. Apparently a decision was
made not to include dialectical behavioral therapy (DBT) in this
volume. Although not technically a cognitive behavioral therapy,
including an update on the latest data on the use of DBT would
have greatly enhanced the last chapter.
Overall, despite the above complaints, I would definitely recommend
this volume. It is quickly read, which is helpful to the busy
clinician and trainee. Nonetheless, there is enough substance
to make the reading worthwhile. The references can provide more
specific information as needed. This book is clearly written
for a professional audience and would likely have little appeal
to other readers.
Shara L. Kronmal writes about herself:
I am a Child and Adolescent Psychiatrist with an interest in depressive and anxiety
disorders in children, teens and adults. I have an outpatient practice of psychotherapy
and medication management through MacNeal Hospital in Berwyn, Illinois. I received my M.D.
and Ph.D. (in Molecular Genetics and Cell Biology) from the University of Chicago and
completed residency and fellowship training in Psychiatry and Child and Adolescent
Psychiatry at the University of Illinois at Chicago. I am an avid reader, hence my
interest in the Metapsychology web site.