In Session: Psychotherapy in Practice最新文献

The personality disorders, having become officially recognized disorders separate from the symptom disorders with the arrival of DSM-III, are prevalent and debilitating conditions that require therapeutic intervention. However, research on the treatment of these disorders has been hampered by the multitude of complex and difficult issues of client heterogeneity, early dropout from treatment, length of treatment needed, manualization of therapies, and measurement of change. The existing research findings are reviewed, with an eye to the clinical implications in the treatment of these clients at this point in time. © 1999 John Wiley & Sons, Inc.

Major advances have been made in the theoretical constructs, classification, and treatment of personality disorders. Nevertheless, these disorders remain very challenging to treat and frustrating to many health care providers. Although we have witnessed a paradigmatic shift in the field of personology, there remains much more to do in this exciting field. A number of parallel trends have been made in diagnostic systems, models that make disorders of personality more understandable and more readily treated with both short-term and long-term psychotherapy. In fact, a number of issues in the field of personality disorders can be described as “breakthrough problems” for the field of psychotherapy and the mental health professions as a whole. This article presents the reader with a summary of these trends. © 1999 John Wiley & Sons, Inc.

This article presents an “anxiety-regulating” model of short-term dynamic psychotherapy that uses the behavioral principles of desensitization to treat psychodynamic conflict. In this model, psychodynamic conflict is reinterpreted as an “affect phobia.” In contrast to phobic stimuli that are external (bridges, snakes), intrapsychic phobias occur within us; the phobic stimuli are feelings. Within this framework, behavioral methods of exposure and the prevention of avoidance can be applied to avoided feelings to resolve the psychodynamic conflict. Clients who are afraid of anger, grief, or closeness are exposed to these feelings in imagery in doses they can bear. Defensive avoidance is prevented and the client experiences the conflicted feeling while learning to regulate the associated anxiety, guilt, shame, or pain. A case example with transcripted segments of sessions is presented to illustrate these principles. © 1999 John Wiley & Sons, Inc.

Cognitive therapy, with its emphasis on structure, time-effectiveness, action, and key thoughts, puts great demands on clients who suffer from Avoidant Personality Disorder (AVPD). Such clients typically shy away from situations in which they feel at risk for failure, rejection, embarrassment, or general discomfort. As such, cognitive therapy potentially presents AVPD clients with the very skills, knowledge, and experience they are lacking, and therefore may be particularly efficacious. On the other hand, the perceived demands of cognitive therapy can scare AVPD clients out of treatment before benefits can accrue; therefore, the therapist must tread lightly. A cognitively based conceptualization of AVPD is presented, along with its concomitant strategies for change. An illustrative case is presented, in which the client learns to chip away at his morbid fear of failure and rejection, and to develop his coping resources through gradual changes in attitudes and daily habits. © 1999 John Wiley & Sons, Inc.

Because personality disorders are resistant to change and difficult to treat, powerful treatments are required. Group therapies are capable of mobilizing strong forces for change. Maladaptive behaviors are commonly demonstrated in the immediacy of the group situation; peer influence can be used to provide feedback and suggestions for change, and new adaptive behaviors can be practiced in the group. Group-oriented day treatment programs are intensive forms of group therapy, and this article describes a particular program that has treated clients with personality disorders for over 25 years. Its intensity is derived from the provision of many hours of group therapy per week to a large number of patients by multiple staff as part of a time-limited integrated system of diverse therapy groups. It is also derived from the implementation of modified principles of the therapeutic community. A case illustration demonstrates how the program is capable of bringing about change at the level of the individual client with a personality disorder. Given the number of clients who can be treated simultaneously, the program is also regarded as time efficient. © 1999 John Wiley & Sons, Inc.

This article reviews the current comorbid clinical syndromes often present in the personality disordered client and offers both theoretical and practical guidelines based on research, theory, and clinical experience. A case of a client with a mixed dependent/avoidant personality disorder and comorbid anxiety disorder is presented, along with transcripts of the last phase of treatment, to demonstrate the process and technique of short-term restructuring psychotherapy, an integrative treatment approach based on psychodynamic principles and utilizing three methods of restructuring—defensive, affective, and cognitive. © 1999 John Wiley & Sons, Inc.

Alcohol dependence not only affects the client but can have a devastating impact on the drinker's family as well. The reactions and attitudes of family members toward the drinker, especially those of spouses of alcoholics who may have endured their partner's problem drinking for many years, are often understandably negative and may hamper recovery efforts. This article describes some of the relationship dynamics common to couples struggling with one partner's alcoholism, and seeks to provide a better understanding of spousal manifestations of expressed emotion. Treatment strategies aimed at reducing high levels of expressed emotion in hopes of preventing drinker relapse are also discussed in the context of couples therapy. © 1998 John Wiley & Sons, Inc.

Borderline personality disorder is a severe form of Axis II pathology characterized by disturbed interpersonal relationships. Widely regarded as being very difficult to treat, problematic family interactions are thought to be central to the etiology and maintenance of the disorder. Recently, empirical research has suggested that higher family levels of emotional overinvolvement might be associated with borderline clients doing better clinically and staying out of the hospital. This article describes a family-based approach to the treatment of borderline personality disorder based on the expressed emotion construct. © 1998 John Wiley & Sons, Inc.

Whereas the literature on borderline personality disorder (BPD) was once exclusively clinical and theoretical, today an accumulating body of research on the nature, etiology, prognosis, and treatment of BPD is of relevance to clinical practice. This article provides a “clinician's guide” to the empirical data on BPD. It begins with a discussion of the evolution of the borderline construct, from early descriptions of a type of patient on the border between psychosis and neurosis, through Kernberg's postulation of a level of disturbance called “borderline personality organization,” through the current DSM conceptualization. In the next section, we examine research on the etiology of BPD, focusing on genetic contributions, attachment histories, and physical and sexual abuse, after which we discuss prognosis, summarizing the results of longitudinal studies. Finally, we address treatment approaches, focusing on psychodynamic psychotherapy, dialectical behavior therapy, pharmacotherapy, and integrative treatment for BPD. © 1998 John Wiley & Sons, Inc.