Treating Personality Disorders in Children and Adolescents: A Relational Approach (Book Review)

Author:  Bleiberg, Efrem
Publisher: New York, NY: Guilford, 2001
Reviewed By: Richard Ruth, Summer 2002, pp. 71-74

This review also addressed another work: Work With Parents: Psychoanalytic Psychotherapy with Children and Adolescents, edited by John Tsiantis London: Karnac, 2000

The organizing fantasy of a book review, to my thinking, is that the reviewer will first create and then convey a quiet, reflective space for thinking over important ideas. It was interesting, then, to try to undergo this process with books about children who either will not or cannot think. In this context, perhaps it will not surprise the reader than this review began with a parapraxis. When I agreed to review these two books and proposed considering them together, I was clear about the terrain of the Bleiberg book—its before-the-colon title, at least, seemed self-explanatory, and two colleagues were reading and talking about it; it had “buzz”—but in my mind I had left off the before-the-colon part (“Work with Parents”) of the other volume’s title.

I was frustrated, as well as a little disquieted and subtly intrigued, by my error. I have read Bettleheim and value what I have learned from him; had I absorbed an inadvertent parent-hatred? Or, as sometimes happens deep into a productive therapy, would my error somehow prove revealingly helpful?

Who are children with severe personality disorders? Their existence was not recognized by the framers of the DSM-IV, who reserved the personality disorder diagnosis only for older adolescents and adults, but both empirical researchers in child psychopathology and psychoanalytic clinicians working with children have described good reasons for applying this diagnostic concept to certain severely disturbed children. The reasons are partly objective—there are a group of children, perhaps growing in number in contemporary society, who are more involved than (take your pick) neurotic categories or Axis I disorder criteria describe, and whose clinical presentation is not primarily marked by psychotic or major affective process. Beyond this, to the extent diagnosis guides and grounds treatment, child clinicians have seized the concept of personality disorder to help us make sense of what is going on inside children whose problematic traits seem robust across developmental time and circumstances, undermine development, and are typically refractory to the helpful generic qualities of a therapeutic relationship and to first-line interpretations of fantasy and conflict.

The category “children with personality disorders” overlaps with other conceptual categories: delinquent children, children with primary deficits, children with constitutional vulnerabilities, traumatized and abused children. Realizing this introduces a certain conceptual fuzziness to the definition of the population being considered in these books, but perhaps it is a fuzziness that exists in and accurately captures nature—and, one must realize, most such children exist in a natural state, as most never make it into serious treatment. The conceptual fuzziness is simultaneously a useful corrective to any tendency to consider these children as some kind of new invention, outside the flow of history. Get beneath the terminology for a moment, and these children readily become children we know well, and do not know well enough.

Bleiberg’s book is a feast of ideas and possibilities, and any therapist who works with children with serious problems (Are there any child therapists left who do not, in this sorry age?), will be enriched by reading it. At the same time, it has some disquieting elements of style.

On the one hand, this book is rich with on-the-edge explications of the neurological substrates of relevant clinical phenomena and how they integrate into theoretically grounded clinical approaches. It has an open-minded, exploratory, integrative sensibility—no dogma here—and it draws heavily on empirical research; at the same time, it unapologetically claims sufficient degrees of freedom to think clinically beyond the point where empirical findings currently leave us on our own. Its bibliography is a treasure trove. Clearly this is a well-read author who can think.

On the other hand, the book is not a graceful read. The sentences are long and dense; the prose feels inadequately edited and too often repetitive; and the type is a bit smaller than usual, as if in an effort to cram more onto the pages than really wants to fit there. Bleiberg, a senior child analyst, with a degree in medicine as well as one in psychology, who has spent his career at Menninger, also writes in the voice and style of his generation. The tone is sophisticated but positivistic, Cartesian, and emphatic: “the therapist must” and “patients will.” We learn surprisingly little about his subjectivity, at least in any direct way, other than that he is blond, has “a Julio Iglesias accent” and likes single malt scotch. Even the sections on countertransference seem largely unrevealing. References to culture are underdeveloped and seem almost token. The engagement with neurological discourse does not extend to an integration of neuropsychology, and the engagement with multiple schools of psychoanalysis is not matched with equal engagement with discourse on gender. A section on gender identity disorder in children seems retrograde and verging on homophobic.

What to make of this? Ignore the chaff, and the chafe, and focus on the ideas? Training tilted me in a charitable direction, but my experience as reader pulled me in another. Perhaps I am projecting, but there seemed to be an undertone in the text rather critical of contemporary practice with this population, particularly the practice of analytically oriented clinicians. There is a fairly constant vector of hinting that we have ignored neuroscience and relevant developments in other schools of therapy, isolated ourselves from marketplace trends to which we need to be more yielding, and failed too many of our patients because of these lacks. The implicit accusation, especially its broadness, did not sit comfortably with me, because it is not what I see reflected in the community of psychoanalytically oriented child therapists in which I work. My sense is that, as a body, more often than not, we are theoretically and technically flexible, creative, dedicated, hard-working, and aware that the children we treat have families, good-enough or problematic attachments (that matter greatly), communities, peers who influence them, and brains as well as minds. As I worked to discern why I was having a sense of an accusation that did not fit, I was led back to the intersection of content and style.

Bleiberg’s central thesis is that the core deficit in children with severe disorders of personality is a lack of what he calls reflective function (Fonagy has called it capacity for mentalization). This refers to an inability or reluctance to turn lived sensation and experience into mental, representational schema, prerequisite to thinking (in Bion’s sense), empathy, getting along with others, and many other processes necessary to development.

Deficits evolve in children with severe personality disorders, Bleiberg says, because of failed attachment processes, which Bleiberg approaches based on the ways that Fonagy and colleagues have elaborated contemporary attachment theory. When children destined to develop severe character pathology seek to attach to parents who may themselves have serious difficulties, including tendencies to abuse their children physically or sexually, what happens becomes unbearable, and the child blocks, destroys or inhibits reflective function as a defense. This permits survival, but at a crippling developmental cost.

Like many synthetic and creative thinkers, Bleiberg constructs his theoretical architecture, and the treatment approach that flows from it, in an elegant, nuanced way, but without a systematic critique of past contributions. This, to me, is both a strength and a weakness of the book, and of much contemporary psychoanalytic writing. When it works, the text can feel refreshingly free of the weight of the musty past. At other times, though, there is a feeling that old things are being called by new names, when the old names would serve at least as well.

After much pondering and reflecting, I am not sure the concept of the absence or presence of reflective function is really very different from Klein’s notion of the paranoid-schizoid and depressive positions. In the paranoid-schizoid position, one cannot metabolize experience through real thought; in the depressive position one can. Bleiberg has access to neuroscientific discoveries that Klein did not, and thus provides useful elaborations, conceptual adjustments and glosses. But it disturbs me that he does not seem to integrate that this element of Kleinian thinking is a not-peripheral piece of his intellectual lineage. Perhaps as a result, while he explores and critiques notions of technique in the tradition of Anna Freud, he is almost silent on technical developments in the Kleinian tradition, which seem the closer fit with the model of pathology he elaborates with such care.


It was at this point in my process that my parapraxis turned more felicitous. The other volume under review here, which approaches a different facet of work with severely involved children, i.e., work with their parents, is essentially is working the same terrain but does not take a similar evolutionary detour. Here, Kleinian and Anna Freudian child therapists, and those of other psychoanalytic orientations, interact more freely.

I think my review will begin to ring less than true if I hold back from inserting some of what I brought to these books at this point, so please bear with me. My background, and my heart, are in community mental health; I am a graduate analyst, trained in the Kleinian tradition; and I practice, teach and supervise child therapy. My daily clinical life is grounded in work with the kinds of children Bleiberg and Tsiantsis and colleagues describe, many of them abused and neglected and deeply, perhaps irreparably damaged; many of them have been failed by previous therapists, and many will undoubtedly be failed by me. I currently see my child patients in my private practice, a far from ideal situation for several of them, who need much, much more than what a private office practitioner can hope to provide. Something of value seems to transpire between my child patients and me nonetheless. However, systems for providing psychoanalytically informed community mental health services to children are collapsing in the US as rapidly as major corporations, and in disturbingly similar ways. The clinic where I worked for 13 years, and the hospital with which it was associated (and where I was a member of the medical staff), Chestnut Lodge, went bankrupt last spring.

At Chestnut Lodge, we were able to help many children of the kind Bleiberg describes. We did not go bankrupt because we were clinically ineffective or even inefficient. Insurance companies that refused to pay us for services we provided in a timely way, management types who would have been at home at Enron, and government’s ultimate refusal to pay for the needs of its neediest did us in. But they did not do me in, or many of my colleagues, or, more surprisingly, many of the patients we treated. We are all still here.

So, I read Bleiberg’s book in a particular way, thinking often about the fact that Menninger still functions and my institution no longer does. I thought about a library one could walk to, colleagues engaged in a free exchange of ideas and with whom one could readily talk in person, seminars and team meetings and research projects and containing structures and processes of all kinds. Bleiberg argues that many, perhaps most, children with severe personality disorders -- the children who have not learned to think -- cannot be treated outside of settings richly provided with these kinds of resources, and the residential treatment they are uniquely able to provide. Perhaps he is right, but if so, he is describing not just a way of working but a place for working few of us are likely to see again.

In the meanwhile, there is Europe, where a different ethos prevails and different kinds of systems of care are funded by different kinds of governments. The organization that sponsored the Tsiantsis volume, fifth in a series, is the European Federation for Psychoanalytic Psychotherapy in the Public Health Services.

Meeting European colleagues who work in the public sector is surprising in many ways, and not at all surprising in others. The writers in this volume are conversant with analytic theory far more than most graduates of even psychoanalytically oriented graduate training programs in this country. Though one hears hints of funding gaps and the intrusive exigencies of mental health systems in these clinical essays, such mentions are more approaching thunder than violent storm. The children under discussion are most certainly the same as those treated in this country, in their externalities –broken families, abuse, severe damage—as well as in what we learn of their inner workings. They are not excluded from treatment because their families lack money or insurance, however.

There are also importance differences in tone in the European volume. This was most apparent in the way I read these books together. At one point, frustrated that I was unable to grasp the clinically relevant kernel in a passage about “autonomic and limbic-hypothalamic activation” in monkeys on the seventh reading (and I have done post-doctoral training in neuropsychology), I put down the Bleiberg book and picked up the other; but I think it would be readily appreciable by any reader.

The writers in the Tsiantsis volume seem less reluctant to speak in the clinical if not the grammatical first person, and have clear opinions about what works and what does not but simultaneously seem more open about the uncertainties and multiple possibilities of approach in their work: more “this is what I try” than “this is what you must do”; more Heidegger than Descartes. The authors convey a sense, which feels much more resonant with my own clinical experience, that work with this population is not just complex but fraught, and can go awry or end too soon for numerous reasons, not all of them within the therapist’s control. Perhaps even more, there is an inference in their work that workaday clinicians have a right to speak. Of the eight essays in the volume, three seem to be written by people with identities as combined clinician-researchers and five by people who are primarily clinically focused. Four essays take up various approaches to work with parents of severely disturbed children; others discuss applications to short-term parent/infant work and to work with parents of psychotic children in a day program, children with autism, and sexually abused children. (In the European idiom, concepts of psychosis and autism seem less tightly or narrowed defined than is typical in the US; reading the clinical vignettes, the overlap with Bleiberg’s more carefully specified population seems clear.)

One of the difficulties I experienced reading Bleiberg was that I could not imagine how to carry what he was writing about into a therapy hour. In some ways this is an unfair request, both of his book and of my fantasy life. We all have a right to some dissociation between what we experience and do in the treatment hour and what we think in the more reflective moments between. But his is an insistent argument: what we analytic child therapists have done historically, and what we are doing still for the most part when we work with this population, is wrong. His core technical recommendation is that, rather than working toward promoting insight through interpretation and promoting the resolution of conflicts in these children, therapists should work to enhance the children’s reflective function, essentially through carefully crafted enactments and working through a corrective emotional experience of the therapeutic relationship. How, then, would he explain work that also seems effective, but that approaches its task in a much more traditional framework?

Interestingly enough, there also seems to be some convergence between these two very different directions and styles of thinking about children with severe personality disorders. Both Bleiberg and several of the writers in the Tsiantsis et al. book talk of working in a collaborative manner with parents, even parents who have abused and deeply damaged their children.

Margaret Rustin, an administrator and longtime senior clinician and teacher at the Tavistock Clinic, writes, in a Kleinian idiom, of a spectrum of ways of working with parents, from supportive approaches and delimited work aiming at ensuring the parents’ willingness to bring the children for treatment through in-depth individual therapy with a parent. What unites this spectrum of approaches, each illustrated by carefully crafted clinical material illustrating how each approach works, is that each derives from the child therapist’s identification with the child and thus their “ready access to the child aspects of our adult patients.” Explicit that she is writing in the context of a setting that no longer, as it once did, typically has psychiatric social workers on-goingly assisting the parents of children in simultaneous long-term treatment, she finds that understanding the primitive, internal dynamics of children and parents can lead fairly directly to focused and creative ways of engaging parents nonetheless.

Strikingly similarly, Viviane Green, who occupies a role analogous to that of Rustin at the Anna Freud Centre, writes in a very object-related way about parent work, in an essay entitled The Child in the Mind of the Parents. Her focus is on understanding how the parents construct the child mentally, and ways child therapists can work with this level of material to engage parents in creating space and support for work with children.

Neither writer, indeed, none of the writers in the Tsiantsis book, demonizes parents, nor do they dissociate awareness that some, perhaps many, of these parents have abused their children. Bleiberg has the same sensibility; some of the most moving parts of his text, to me, are those where he speaks with deep compassion for how hard it is for some of the parents he brings alive in his anecdotes to understand and nurture their personality-disordered children, and how hard it is for their children to make use of parental provision even when it becomes available, from the parent or, in the therapeutic relationship (he would not, in this context, say “transference”), in analogous fashion from the therapist. (This, by the way, seems to be what Bleiberg means by the after-the-colon part of his title, “A Relational Approach.” He is not referring to ideas from relational psychoanalysis.) However, while Bleiberg also values and uses analytically derived insight into his patients’ dynamics, his interventive focus is more on action than repair through insight. Where Rustin might describe a shift into a depressive position as catalyzing a series of positive changes, or Green might see the parents’ restored mental representation of a whole, complex child as the fulcrum of change, Bleiberg focuses on therapists correcting children’s cognitive errors and building reflective functioning in children and parents.

Although all children, and child therapists, struggle to parse out the roles of doing and of thinking, perhaps in the end these poles are not as opposite from each other as it might often seem or feel. Reading these valuable contributions, I am struck with both how much we have come to understand about children with severe personality disorders, and how much still needs to be clarified, weighed, sifted and integrated. These are daunting children, and the more we understand them and let them into our own thinking, the more daunting yet they can feel. Thus I am very grateful for the help these gifted clinicians and deep thinkers extend to us, and I think the gratitude should flow from the larger community of psychoanalytic psychotherapists as well. If we are to claim our place in the brave, and frightened, new world in which we live, it will be in no small part, I think, because we are able to take the necessary work with the kinds of children under consideration here in effective directions others are unwilling, and unable, to pursue.

Reviewer Note

Richard Ruth, PhD, is a member of the steering committee of the Child and Adolescent Psychotherapy Program of the Washington School of Psychiatry and in private practice in Wheaton, Maryland.

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