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Well here we are again at about 30,000 feet in the air. I seem to do most of my writing while flying. Or maybe it's an analogy for the subject at hand, treating personality disorders. That is, we fly high and fast and most of the time we end up back were we started. I guess the question that comes to mind is "What did we learn along the way?"
In the last column we discussed the various types of personality disorders and now we are moving on to treatment. There are two general approaches: The first is to delve deeply into the psyche to effect a profound change in the patient's personality, while the second is to treat the symptoms and bolster the positive aspects of the patient's personality.
Let me diverge for just a moment. Why bother treating these individuals at all? Is not fate that which determines who and what we are? While fate may have determined who we are, we are responsible for what we do. What about just telling the person to "cut it out, start acting like an adult and not a child"? Well, the simple answer is that if these persons could "cut it out", they would. Not only are they in tremendous pain (psychic pain hurts just as much as body pain) because of their behavior, they also cause profound pain in the people they are in contract with, e.g. family. Probably the best similarity in body medicine is patients with chronic illnesses like diabetes, COPD and coronary artery disease. These illnesses are long term and change both the individual and the family. Now that I have diverged and stressed how important it is to treat this group of illnesses let us return to treatment.
Unfortunately, I must confess that the effectiveness of treatments for personality disorders is difficult to determine and many treatments probably have only marginal benefit. But as there are no other options, treat we must.
The main form of treatment of personality disorders is psychotherapy. What is psychotherapy? If you ask 10 therapists you will get 10 different answers. I will get more specific about the types a little later. Right now I will attempt to answer this question without using technical jargon, A.K.A.. psycho-babble. Psychotherapy represents a relationship. Not a friendship or a work acquaintance, though there are common elements. In this important relationship you are exposed to a model of relationships that can be used outside the therapy. Psychotherapists are trained in the rules and techniques for their specific school of thought and use their skills to effect a change in the patient.
All relations have rules, and different relations have different rules. For example the first relationship is the mother-child. The rules are something like the following: child is born helpless and mother agrees to provide all the care needed to ensure the child's well being. As the child grows, the rules are modified. Ideally, early on the mother provides all that is needed and as the child grows and becomes more independent, the mother gives the child more autonomy. Finally at some point the child is no more and an independent person exits.
These rules are not agreed upon but are inherent in the relationship. If the rules are not followed, then there is an increased likelihood that the child will have more difficulty in adult relationships. However, even with perfect early childhood parenting relations, not everyone grows up normal . And many raised in less than perfect situations often grow up normal. So it is with psychotherapy - except that the rules are agreed upon.
Now, the therapist and patient agree on the rules of each psychotherapy. In the case of a therapy called psychoanalysis the therapist agrees to show up for scheduled appointments, provide a environment for therapy and use skills that will bring repressed memories and feeling to the conscious. The patient agrees to be honest, compliant, forthcoming with their thoughts and to pay for the service. Notice I used the term "patient" not "client" and I must digress once more. Most non-medical psychotherapists use the phrase "client" to describe the receiver of the therapy. When psychotherapy is preformed by a physician, usually a psychiatrist, the relationships have both psychotherapeutic and physician/ patient components. This also means that there are different rules for physician therapists than non-physician therapists. Physicians treat patients and are bound by the Hippocratic Oath. Non physician therapists are bound by the Hippocratic Oath and treat clients. Both groups may use the same therapy techniques of which many abound.
Here is a list of several different therapies: It seems that each school of psychotherapy believes that they are the most useful for most occasions. I have found that the success of the therapy depends on the abilities of both the therapist and patient. That is, the therapist must have the technical and emotional skills and the patient needs to be motivated and have the right psychological resources. Let me emphasize that if therapy has any chance to succeed. the patient must want to change. This brings to mind several jokes, but lets save that for another time
Psychoanalytic including psychoanalysis and supportive psychotherapy attempts to uncover the unconscious elements involved in thoughts and feelings. Behavioral therapy focuses on behavior and not upon what is thought of as the reasons for a person's individual psychological structure. This field includes cognitive therapy. Cognitive therapy of all the therapies has the most scientific basis to support that it works.
Transactional therapy deals with social interactions, and guided imagery therapy with visualization techniques. Other therapies include feminist psychotherapy, brief therapy, interpersonal therapy, family therapy, couples therapy, group therapy, hypnotherapy and psychodrama. This list of psychotherapies is incomplete, but all therapies listed here have proven track records, though little in the way of reproducible scientific studies. If you feel your problems are best addressed by psychotherapy, consider talking with a therapist of several different schools to see which one suits you. For example if you like to think a lot about who you are and how you became you, psychodynamic may be your cup if tea. However if you are not a big talker and want to concentrate on changing behavior then cognitive-behavior therapy may better suit you.
This last part of the column is not going to be long. That is because it addresses the use and effectiveness of medications to treat personality disorders. The reason it is short is that there is no medication that can cure problems of personality. What medications can offer is temporary relief of symptoms. In previous columns I have talked about different medications and they may have a role from time to time. For example if a patient is impulsive and depressed, a medication like Prozac may be helpful. As another example, if one is overcome by suspiciousness, a drug like Haldol may be useful. The job of determining which medication to use and how much to administer is an art, and best left to the psychiatrist.
© 1998 Peter Melgaard Thompson
Last Modified: August 15, 1998
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