Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology (Book Review)

Author:  Caligor, Eve, Otto F. Kernberg & John F. Clarkin
Publisher: American Psychiatric Publishing, Washington, DC, 2007
Reviewed By: Brian H. Stagner, PhD. XXIX, no. 3, Summer 2009, pp. 56-57

In the past three decades we have seen an enormous number of books and articles that discuss severe personality disorders from many viewpoints, including classification, development, phenomenology, and treatment strategies. These disorders are intriguing and perplexing in their own right and for the light they may shed on personality development in general. Given the vexing and costly demands posed by this population, the volume of literature is not surprising. However, for most clinicians the more primitive personality pathology is relatively uncommon. For the majority of practitioners in outpatient settings (and that is most readers of this publication), the prototypical client more often presents with problematic symptoms in the context of higher order pathology. There has been, however, very little systematic guidance for treating this population.

This handbook, offered by leading figures in the study of psychodynamic therapy and severe character pathology, is intended to fill this need. It is also an acknowledgement that in many areas of psychology and psychiatry our knowledge has advanced beyond a one-size-for-all treatment attitude. We should expect treatment strategies to be individually tailored and grounded in substantive evidence of effectiveness. The present work is an outgrowth of efforts to develop empirical support for transference focused psychotherapy (TFP) which is described in a treatment manual for addressing borderline personality (Clarkin, Yeomans, & Kernberg, 2006). This volume is offered as a companion to that manual.

Dynamic Therapy for Higher-level Personality Disorder (DPHP) focuses on individuals who are able to function fairly well in situations requiring adaptation to the everyday. Having a relatively stable sense of self, they may function well in work settings but are impaired in forming relationships: primary attachments may be short lived and/or dysfunctional, collegial relationships may be distant, and distance and alienation may displace the capacity for reciprocal interactions. As a result, despite superficially successful adaptation, these clients may experience chronic anxiety, depression and dysphoria. In contrast to the individuals with lower level personality pathology, the DPHP patient population does not experience storms of identity diffusion, transient psychotic states, or episodes of extreme recklessness that characterize more primitive borderline conditions.

DPHP has been developed to help patients become aware of the inefficient defenses they rely on and the underlying psychological conflicts these defenses are designed to ward away from awareness. The premise is familiar. The therapist enables the emergence of these conflicts in the therapeutic relationship where they can be brought into consciousness safely examined. Rather than cling rigidly to these defenses, the client can begin to understand their historically self-protective function. At roughly the same time, the therapist helps the client tolerate the parts of the self that have been split off earlier in development and bring them into conscious awareness. As a result, the need for rigid defenses will attenuate, resulting in more flexibility and a richer, deeper emotional life. The goal is not (as with other therapies, including short term psychodynamic treatments) to alleviate symptoms but rather to effect modification of the rigid features of the personality that exacerbate symptoms. On the surface the components of DHP are quite familiar: the therapist established a frame, facilitates the therapeutic alliance, attends to manifestations of the transference, monitors countertransference, offers interpretations, and helps contain the anxieties aroused by the therapy.

Granting the conceptual familiarity of the approach in general, what are the specific areas of overlap and departure from psychoanalysis in general or the TFP model in particular? A relatively cursory reading left this reader feeling that DPHP is just TFP-LITE: psychoanalysis, only less so. Despite theoretical overlap, important differences do emerge at the pragmatic level. For example, consider the role of transference in the treatment. While transference phenomena (thoughts, enactments, acting out) are important for most psychoanalytic treatments, the degree to which the therapy works explicitly through the transference may vary a great deal across cases. While some treatments will proceed by examination of the relationship, in other cases the therapeutic relationship is shielded from disruption and the patient expresses conflicts in the context of other relationships. Thus interpretations will be based both on transference and extratransference material, on the assumption that the same conflict may be activated in either arena and the patient may be more able to profit from one interpretation than the other.

A more general distinction is that, while psychoanalytic therapists may be cognizant of the broad range of a patient's inner life, conflicts and personality rigidity, DPHP narrows the focus to work only on the core conflict issues that are central to the presenting problems and the treatment goals outlined when the frame was established. This implies great attention to assessment and case formulation t the outset, and both the theoretical formulation of higher functioning personality disorders and the conceptual tasks involved in assessment are described with clarity and brevity.

DPHP prescribes techniques for listening and intervening with the client. Again, there are no radical departures from other psychoanalytic therapies and these chapters provide a succinct overview. More detail and specificity is found in the subsequent chapter on specific DPHP tactics. The authors urge therapists to anticipate that one or two issues will become organizing themes within a session. They describe a decision tree for identifying where to intervene:

1.  Are the patient's communications relatively open and free?

2.  Which issues are affectively dominant for the patient at the moment?

3.  If the theme is unclear, what object relations conflicts are being enacted in transference?

4.  What issues are being activated in countertransference?  

The second tactical objective is the identification of the conflict and the defense by looking at the relationship patterns. When these patterns are easily brought to consciousness they may serve a defense, a clue to how the patient is consciously experiencing himself or herself in the session. To discover the conflict the therapist may wonder how the patient would respond from the opposite end of the conflict or what feelings are avoided by this defensive object representation? Further, we may wonder why the patient needs to invoke this defensive relationship representation at this particular moment.

The third stage involves analyzing the conflict, moving from the surface to deeper material. As the authors note, good practice dictates starting with dissociative defenses---operations based on splitting off certain aspects of experience (self or other representations) and moving to defenses based on repression and neurotic projection. Finally, as this process uncovers the dominant underlying conflicts the therapist returns to consider how these conflicts link to the treatment goals. A substantial portion of this compact handbook is devoted to explicating this process. The discussions are brief but very coherent, and the brevity is balanced by the excellent clinical examples. The result is a very illuminating overview of treatment that will be accessible to both veteran and novice clinicians.

Beyond the generally excellent explication of DPHP, two areas deserve special notice. A unique and especially helpful contribution of this book is a fairly detailed discussion of how this psychoanalytically based therapy can be combined with other treatment methods. This includes discussions of the simultaneous or sequential integration of DPHP with interpersonal, cognitive/behavioral, or pharmacological interventions for patients with depression or anxiety. This discussion is thoughtful and grounded in the authors' clinical experience. Readers will take away a deeper understanding of the issues involved and a well-developed rationale for treatment planning in cases that call for multimodal interventions.

The second positive feature is the artful use of clinical examples. Scattered throughout the text, the clinical material is, without exception, succinct and highly illustrative. This is hard to do well, but it is clear that the authors gave great care to making a book that is a very accessible teaching text for readers at any level.

On the negative side, this volume has little to offer in response to criticism that psychoanalytic therapies lack adequate evidence of efficacy. The authors correctly note that DPHP is an outgrowth of a model that has received much investigation; it is the logical next step in the investigation of psychoanalytic approaches to personality disorders that has been at the center of research for the past thirty years, to which Kernberg has been a seminal contributor at both a theoretical and practical level. On the other hand, there is little here to augment efforts that would meet the evidentiary criteria that will confirm efficacy to third party payers and policy makers. However it is unfair to complain too loudly about something that the book does not really attempt to accomplish. Suffice it to say that this is an excellent overview of how a well-established treatment (TFP) can be adapted to the particular circumstances of the higher functioning patient. It is potentially an excellent teaching text, and it will also be a useful volume for seasoned practitioners.

Reference

Clarkin J.F, Yeomans, F. & Kernberg, O.F. (2006). Psychotherapy for borderline personality: focusing on object relations. Washington, D.C., American Psychiatric Publishing.

Reviewer Note

Brian H. Stagner
College Station, TX
bstagner@psych.tamu.edu

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