Personality-Guided Therapy for Depression (Personality-Guided Psychology)

Citation preview

PERSONALITY^GUIDED PSYCHOLOGY BOOK SERIES THEODORE MILLON, Series Editor Personality-Guided Therapy for Posttraumatic Stress Disorder George S. Everly Jr. and Jeffrey M. Lating Personality-Guided Therapy in Behavioral Medicine Robert G. Harper Personality-Guided Forensic Psychology Robert J. Craig Personality-Guided Relational Psychotherapy: A Unified Approach Jeffrey J. Magnavita Personality-Guided Cognitive-Behavioral Therapy Paul R. Rasmussen Personality-Guided Behavior Therapy Richard F. Farmer and Rosemery O. Nelson-Gray Personality-Guided Therapy for Depression Neil R. Bockian

Personality-Guided Therapy for Depression Neil R. Bockian

Series Editor Theodore Millon

AMERICAN

PSYCHOLOGICAL

ASSOCIATION

WASH I N G T O N ,

DC

Copyright © 2006 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 www.apa.org To order APA Order Department P.O. Box 92984 Washington, DC 20090-2984 Tel: (800) 374-2721; Direct: (202) 336-5510 Fax: (202) 336-5502; TDD/TTY: (202) 336-6123 Online: www.apa.org/books/ E-mail: [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from American Psychological Association 3 Henrietta Street Covent Garden, London WC2E 8LU England Typeset in Goudy by Stephen McDougal, Mechanicsville, MD Printer: Edwards Brothers, Ann Arbor, MI Cover Designer: Berg Design, Albany, NY Technical/Production Editor: Harriet Kaplan The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Library of Congress Cataloging-in-Publication Data Personality-guided therapy for depression / by Neil R. Bockian. p. cm. — (Personality-guided psychology) Includes bibliographical references and index. ISBN 1-59147-410-8 (alk. paper) 1. Depression, Mental—Treatment. 2. Personality disorders—Treatment. I. Title. II. Series. RC537.B58 2006 616.85'2706—dc22 British Library Cataloguing-in-Publication Data A CIP record is available from the British Library. Printed in the United States of America First Edition

2005037362

Dedicated with love to my wife Martha— my personal antidepressant and my favorite personality type.

CONTENTS

Series Foreword

ix

Preface

xi

Acknowledgments

xiii

Chapter 1.

Introduction

3

Chapter 2.

An Overview of Depression and Theoretical Models of Its Relationship to Personality Disorders

13

Chapter 3.

Depression in Paranoid Personality Disorder

41

Chapter 4.

Depression in Schizoid Personality Disorder

63

Chapter 5.

Depression in Schizotypal Personality Disorder . . . .

91

Chapter 6.

Depression in Antisocial Personality Disorder

109

Chapter 7.

Depression in Borderline Personality Disorder

135

ChapterS.

Depression in Histrionic Personality Disorder

169

Chapter 9.

Depression in Narcissistic Personality Disorder . . . .

187

Chapter 10.

Depression in Avoidant Personality Disorder

209

Chapter 11.

Depression in Dependent Personality Disorder

227

Chapter 12.

Depression in Obsessive-Compulsive Personality Disorder

247

vu

Appendix A: Emotion List—2

267

Appendix B: Expression of Personality Disorders Across the Domains of Clinical Science

271

References

273

Author Index

305

Subject Index

313

About the Author

325

viii

CONTENTS

SERIES FOREWORD

The turn of the 20th century saw the emergence of psychological interest in the concept of individual differences, the recognition that the many realms of scientific study then in vogue displayed considerable variability among "laboratory subjects." Sir Francis Galton in Great Britain and many of his disciples, notably Charles Spearman in England, Alfred Binet in France, and James McKeen Cattell in the United States, laid the groundwork for recognizing that intelligence was a major element of import in what came to be called differential psychology. Largely through the influence of psychoanalytic thought, and then only indirectly, did this new field expand the topic of individual differences in the direction of character and personality. And so here we are at the dawn of the 21st century, ready to focus our attentions ever more seriously on the subject of personality trait differences and their impact on a wide variety of psychological subjects—how they impinge on behavioral medicine outcomes, alter gerontological and adolescent treatment, regulate residential care programs, affect the management of patients with depression and posttraumatic stress disorder, transform the style of cognitive—behavioral and interpersonal therapies, guide sophisticated forensic and correctional assessments—a whole bevy of important themes that typify where psychologists center their scientific and applied efforts today. It is toward the end of alerting psychologists who work in diverse areas of study and practice that the present series, entitled Personality-Guided Psychology, has been developed for publication by the American Psychological Association. The originating concept underlying the series may be traced to Henry Murray's seminal proposal in his 1938 volume, Explorations in Personality, in which he advanced a new field of study termed personology. It took its contemporary form in a work of mine, published in 1999 under the title Personality-Guided Therapy.

The utility and relevance of personality as a variable is spreading in all directions, and the series sets out to illustrate where things stand today. As will be evident as the series' publication progresses, the most prominent work at present is found with creative thinkers whose efforts are directed toward enhancing a more efficacious treatment of patients. We hope to demonstrate, further, some of the newer realms of application and research that lie just at the edge of scientific advances in our field. Thus, we trust that the volumes included in this series will help us look beyond the threshold of the present and toward the vast horizon that represents all of psychology. Fortunately, there is a growing awareness that personality variables can be a guiding factor in all spheres of study. We trust the series will provide a map of an open country that encourages innovative ventures and provides a foundation for investigators who wish to locate directions in which they themselves can assume leading roles. Theodore Millon, PhD, DSc Series Editor

SERIES FORWORD

PREFACE

The science and practice of clinical psychology have undergone a dramatic and exciting process of change in the past century. Following Freud's explorations of the unconscious, the dialectic swung to the antithesis, the behavioral revolution of Thorndike and Watson and, later on, Skinner. Filling in the vast space since then have been many approaches. Objectrelations theorists have examined the functioning of the ego, and interpersonal theorists have studied how relationships with others impact human psychology. Client-centered, humanistic, and existential therapists as well as logotherapists have focused on human experience and questions regarding life's meaning. Systems-oriented theorists have helped us to understand dyads, families, groups, and organizations and have developed new and innovative intervention strategies. Cognitive and rational—emotive therapists have discovered a wealth of techniques designed to help the individual use reasoning to feel better. With each new theoretical innovation, the discipline of clinical psychology has found new ways to be helpful and to reach more individuals. Efforts at integration have become increasingly important. There were theoretical manuscripts integrating, for example, individual and family approaches (e.g., Wachtel & Wachtel, 1986) or psychodynamic and behavioral approaches (Arkowitz & Messer, 1984). Millon's (1969/1985) biopsychosocial model makes the case that biological, psychological, and social factors contribute to a person's overall adaptation; this approach had a substantial impact on the field. Previous efforts at integration focused mostly on the level of theory— that is, the effort was to find commonalities in different theoretical approaches or to add the strengths of one to another. With Personality-Guided Therapy (1999), Millon added the notion that the best way to integrate theories was to focus at the level of the person. Simply put, psychodynamic, behavioral, cognitive, family, humanistic, and other theories can all be used to describe XI

a single individual. From that perspective, it becomes apparent that a given individual has unconscious conflicts and behavioral tendencies and cognitions and family dynamics and experiences of conditions of worth, all of which contribute to his or her current functioning. In line with the biopsychosocial perspective, it becomes equally obvious that biological and sociological phenomena also have a substantial impact on the person. The best available picture of an individual at any given moment is a collage of all of the concepts and images contributed by each perspective. The purpose of this book is to provide a comprehensive understanding of the person with clinical depression. By taking into account personality, as represented by the personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, ZOOOa), treatments for depression are refined and made more appropriate. Along the lines of the growing and healthy interest in positive psychology, we (the author and the series editor) are also mindful to take into account strengths and positive aspects of the person. From a scientific standpoint, we see this book as part of an ongoing process. There is a synergistic flow between clinical practice and science (Soldz & McCullough, 2000). Practice leads to insights that generate hypotheses to be tested scientifically; research then informs clinical practice (Anderson, 2000). Like the developers of process-experiential therapy (Elliott, 2000) and transference-focused psychotherapy (O. F. Kemberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989; Yeomans, Clarkin, & Kernberg, 2002), we envision practice and research mutually enhancing one another, leading to many confirmations—and just as many surprises—along the way. Ultimately, our goal is to operationalize the approach and test it in randomized clinical trials. In the meantime, we invite the reader to join us in exploring this promising new approach.

PREFACE

ACKNOWLEDGMENTS

I thank the many people who made this book a possibility. First and foremost, I thank the series editor, Theodore Millon, who asked me to write the book. Ted, your faith and confidence in me have consistently exceeded my expectations of myself and inspired my best work. The dedicated and talented editors in the American Psychological Association Books Department have done a wonderful job of shepherding this project to fruition: Susan Reynolds guided me through the opening phases, and Linda McCarter has been a steadfast support for some 2 years. I also thank several gifted clinicians, my former students Don Castaldi, Mark Johns, Suzanne Richter, Michelle Rodgers, and Kelly Vinehout, all of whom provided case material; their contributions considerably enhanced the quality of this volume. In addition, I thank the anonymous reviewers, who provided feedback that dramatically improved the quality of the book while simultaneously improving the economic welfare of the coffee industry. The librarians at the Illinois School of Professional Psychology Chicago Campus deserve high praise, especially Qi Chen, who added several books to the library collection at my behest, and Fay Kallista, who tirelessly tracked down articles and interlibrary loan materials. The members of the library staff at the Adler School of Professional Psychology, Karen Drescher, Arlene Krizanic, and Michael Zellner, also provided a number of articles, some of them on an expedited basis; to them I owe my thanks as well. Hundreds of current and former students have contributed to this book through their participation in my countertransference study, their completion of their clinical research projects in areas related to this work, their questions and comments in class, and their homework assignments; from them, I have learned more than can be imagined. I appreciate the efforts of my current students and future colleagues Julia Smith and Ellyn Turer, and of former student Virginia Doyle South, who provided feedback on the initial draft. In addition, I thank Danielle Merolla, Erica XIII

Moore, and Dominika Prus, who proved to be worthy assistants during the time-pressured final phase of preparing the manuscript. My parents, Fred and Sandra, and my uncle and aunt, Alan and Barbara Brodsky, provided encouragement, emotional support, and that most precious support of all—babysitting! Special thanks go to my brother Jeffrey for what must be the most memorable portion of my writing. When a longplanned vacation together bumped up against my first draft deadline, he adapted his SUV into a traveling office, and I wrote two full chapters on the round-trip drive between Los Angeles and Death Valley. I also thank my sister-in-law, Kari, who supported our dusty adventure. I am grateful to my wife, Martha, for taking on extra responsibilities while I wrote, despite her own rapidly burgeoning career and growing opportunities. Finally, I thank my beloved children, Chaya and Yaakov, who groaned each and every time I needed to work on the book and never became the slightest bit acclimated to my need for additional time; may we always yearn to spend our moments together.

xiv

ACKNOWLEDGMENTS

Personality-Guided Therapy for Depression

1 INTRODUCTION

Depression is a thorny problem to treat. In many cases, treatment is ineffective from the start. Even when client and clinician meet with early success, relapse frequently follows. Given that millions of people suffer from the disorder, improving treatment for depression is a major priority. The premise of this book is that those individuals who have depression and either fail to make progress or experience relapse often do so because of deeply rooted, enduring patterns in numerous areas of their lives that conspire to undermine healthy and satisfactory adjustment. Personality shapes how the individual exists in the world. It is the riverbed upon which the person's emotional life flows. In order to change the direction of a complicated depression, one is well advised to intervene at the level of personality. More specifically, the very nature of the depression itself and the reason the person has become depressed is explicitly related to the individual's personality style or disorder. For example, where the person with a dependent style mourns being abandoned, the person with an antisocial personality configuration agonizes over feeling confined. Such considerations have implications for treatment. Intervention must not only address different issues but different communication styles. Thus the nurturing, supportive approach that would endear one to the dependent client would elicit denigration from the antisocial. 3

To be sure, as we have known for many years, many straightforward cases of depression are successfully treated in 20 sessions or fewer (A. T. Beck, Rush, Shaw, & Emery, 1979). Such cases are not the focus of this volume; rather, my focus is those cases that have "complications" and are likely to either fail or to relapse. Research supports the commonsense notion that individuals who have both personality disorders (PDs) and depression have more problematic recoveries (Ilardi, Craighead, & Evans, 1997). This volume provides conceptual guidelines on how to be effective in these difficult cases. Depression is influenced by behavioral problems, such as poor social skills, as well as by beliefs of personal inadequacy and ineffectiveness. Unconscious phenomena such as repression or intrapsychic fragility can impact both mood and behavior. Most depressions also involve interpersonal problems, such as family difficulties, conflicts, or withdrawal. Biological predispositions often contribute to the difficulties of depression. Personality theory serves as an excellent conceptual framework through which to understand how these various factors interact synergistically to produce problems. Similarly, personality theory provides a framework to understand many strengths an individual has that facilitate long-term recovery. It is well known that PDs are also difficult to treat. They are, by definition, long-standing and deeply ingrained. A depression may make a PD more difficult to treat, particularly in the case of those with "internalizing" personality styles who tend to be hard on themselves or intropunitive (e.g., avoidant or obsessive—compulsive) or those who are already slow and passive (e.g., schizoid or dependent). On the other hand, depression may facilitate treatment among those with "externalizing" personality styles, who might otherwise be hesitant to engage in treatment (e.g., are narcissistic or antisocial). As with the notion presented above, that taking personality into account will facilitate the treatment of depression, 1 assert that taking depression into account can improve the treatment of PDs. The aim of this volume is to provide practitioners, researchers, and students with a theoretical framework from which to approach the individual who has depression embedded within the context of a particular PD or style. Because it is based on the integration of well-grounded approaches, the current volume provides ideas that will be useful for clinicians. I am equally hopeful that the text will provide fertile ground for testable hypotheses for researchers. Indeed, this volume marks one important step in an ongoing scientific journey. Eventually, personality-guided therapy must be subject to randomized clinical trials (RCTs) to determine whether it lives up to its promise of increasing success rates and reducing relapse rates of individuals with complicated depressions. This volume is a step toward developing a treatment that is defined with sufficient precision to be manualized and thus subject to RCTs. In addition to RCTs with manualized interventions, efficacy studies with naturalistic designs are necessary to see how the therapy functions in the "real world." 4

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

THERAPIST EMOTIONAL REACTIONS: COUNTERTRANSFERENCE Although it is beyond the scope of this work to cover countertransference in a comprehensive manner, looking at all of the available literature (a project of that magnitude is worthy of a book in its own right), I will make some comments on therapist emotional reactions to people with each of the PDs. Rather than exhaustively review the literature, or leave out countertransference entirely, I have chosen to report some of my own experiences, an abbreviated review of the literature, and the findings of a research project that I have undertaken for the past 7 years. Although these findings are not yet published, there have been a few presentations based on these data (Agor, Smith, & Bockiari, 2005; Bockian, 2001, 2002a, 2002b), as well as several clinical research projects (Agor, 2005; Kim, 2004; Mullen, 2004; Rodgers, 2004; Rusten, 2002; D. L. Williams, 2005). In the study, graduate students in clinical psychology were shown film clips of individuals with PDs. They were then asked to rate their emotional reactions on the basis of a 136-item adjective checklist (see Appendix A). Participants in the study also gave descriptions of the meaning of the adjectives that they endorsed. The data I am reporting came from approximately 900 such forms collected from about 250 participants. Throughout the text, this study is referred to using the presentation in which the largest portion of the data was presented (Bockian, 2002a). For the purposes of this book, the most important finding is simply the mean of the participants' ratings of their emotional reactions to the film clips. However, it is noteworthy that manipulation checks suggest that the films are adequate prototypes of the PDs they are supposed to represent. Mean ratings of the prototypicality of the film clips, and how well they represent the PD they portray, are approximately 7.5 to 8.0 on a l-to-10 scale. The main drawbacks of the research paradigm are that (a) it is not clear how similar participants' reactions would be to real clients with whom they were interacting, as opposed to film clips; (b) it is not clear how their reactions would evolve over time, as opposed to seeing just a 5- to 10-minute segment of an intake session; and (c) it relies on conscious reports entered on a self-report instrument, thus banking on the self-awareness and accuracy of the participants. The main strength of the paradigm is that the stimulus is constant, so that reactions can be aggregated across clinicians. I routinely use two strategies to deal with feelings that I have toward clients, including positive feelings, but especially negative feelings. The first step is to become aware of the nature of the feeling itself. The emotional reaction typically occurs as a "felt sense" (Gendlin, 1978)—a vague, diffuse, nonverbal feeling. I also often experience a somatic response. Identifying these experiences and then labeling them ("oh—I'm bored!") is something I find to be useful, not only in recognizing the problematic pattern in the client (e.g., schizoid PD), but also in finding ways to "sit with my feelings." INTRODUCTION

5

The process of paying attention to one's own reactions is a useful exercise, one that can be conceptualized under the rubric of mindfulness (Epstein, 1995; Kabat-Zinn, 1990, 1994). Mindfulness, which is derived from the vipassana school of Buddhist meditation, is a form of self-awareness that can be practiced on a regular basis. For therapists, engaging in regular mindfulness practice is a way of managing one's personal stress while improving one's self-awareness (Bockian, 2001, 2002b). Once the feeling has been labeled, one can simply sit with it—sitting with unpleasant feelings has deep roots in mindfulness practice. One often finds that when one is "fully present in the moment" the discomfort itself dissipates. As a client of mine once put it, "When I'm rushing around, trying to run my business, I feel like I'm going to explode. But when I stop, and return to my breath, and focus on what's happening right now, it's never that bad." Thus, sitting with boredom, just for this moment, is never that bad. One can also explore the feelings using thought records, a technique taken straight out of cognitive-behavioral therapy (CBT). Once practiced, it can be done during the session, while one is still paying attention to the client. This approach may be incompatible with a client-centered approach, or the mindfulness approach above, because it entails multitasking, and thus one is not fully present with the client. From a CBT perspective, however, I believe this would be an acceptable, and even encouraged, approach (see A. T. Beck, Freeman, 6k Davis, 2004; Ellis, 2001). As I thought about some bored feelings I had when watching a filmed simulation of a client (Fidler, 1989), I would reflect to myself, I'm feeling bored. What is the situation? He's talking about his dinner in response to the question about what he is thinking about. What is the thought connected to that boredom? He is answering my questions in ways that do not connect to other people. I don't really care about what he is going to have for dinner. 1 am interested in how he will plan his life out, what he will do now that he lost his job, and so on. I then become aware of another feeling, a slight feeling of irritation, connected to the thoughts "he should be planning out his future, he is wasting valuable time with the counselor, who is trying to do career planning with him." Once the thoughts and feelings are connected, they become rather easy to challenge. What is the client's understanding of the purpose of the sessions? Has he been educated appropriately about the reason for the referral? What does he need, from his perspective? Another direction I routinely go in when examining my emotional reactions is to imagine what it would feel like to be that person, dealing with someone who felt like I did. What if everyone—or many people—felt that way about him? What would it be like if others found me boring because I did not have intense reactions to things, or irritating because my responses were

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

"off or inconsistent with expectations? Such thoughts tend to lead me toward a more empathic stance. I will then check out the validity of my assumptions by asking about his interactions with others and how others respond. Implicitly, then, I am suggesting that countertransference is generally extremely useful in helping clients. Of course, countertransference can also be so difficult to manage that it can damage the therapeutic relationship. In the chapters that follow, I outline some commonly reported countertransference reactions as well as some common pitfalls to avoid. PERSONALITY-GUIDED THERAPY Millon's personality-guided therapy (POT) approach is more than sequencing different therapies. The concept of catalytic and synergistic effects in therapy has important implications for treatment. The chapters of this book are organized to provide different approaches and findings based on theory-driven modalities. However, I hope to capture the essence of PGT in the case studies: simultaneous integration of the entirety of the person, including personality, diversity, and other unique factors, along with properly timed sequential interventions drawn from a variety of theoretical sources. From the standpoint of PGT, the treatment of PDs and depression does not constitute two separate processes. Within the medical model, on which the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) is largely based, diseases can be separately diagnosed and treated. Thus, the individual with cancer and depression may receive radiation therapy for the cancer and pharmacotherapy for the depression, and the treatments may not react with one another. In PGT, the treatment of the PD tends to resolve the depression, and vice versa; the disorders are not truly separable. This becomes clear in many of the case studies. There is a fine example in chapter 6, in which the person has depression and antisocial PD. The client was depressed because of his hopelessness about ever being released from prison and because of his frequent placements in solitary confinement precipitated by his violent behavior. The intervention, in a sense, directly targeted the PD. The client needed to better understand his relationship to authority and how his conceptualizations overly constricted his options and choices, especially regarding his violent behavior. Once he became more in control of his violent behavior, he was no longer placed in solitary confinement, and his chances of release improved; consequently, his depression began to resolve. Treating "the depression" (e.g., with techniques that addressed typical depressogenic cognitions, such as assessments that he was worthless, "must" statements, and so on) would not have been effective, because such thoughts were too distant from the client's experience. The depression had to be treated in the INTRODUCTION

context of the person. Throughout the text, there are many sections in which I discuss methods for understanding and resolving PDs; the reader should be aware that these conceptualizations and interventions address, directly or indirectly, the individual's depression as well. The integration of well-established treatment modalities in a systematic fashion is one of the central features of PGT. In this regard, Millon (1996, 1999) has provided a guiding, comprehensive theoretical framework that integrates the work of most if not all of the major theoretical perspectives into a coherent system. It is reminiscent of the well-known Indian parable of the blind men investigating an elephant: One, grasping the leg, proclaims that the object is a tree; a second, feeling the trunk, declares it is a snake; a third, handling the tusk, believes that the elephant is a spear, and so on. The blind men then take to arguing among themselves about the true nature—or even the proper description—of the elephant (Saxe, 2002). The main point is that taken one by one, none of the descriptions adequately captures the nature of the elephant. The pointless squabbles that have permeated our discipline regarding "who is right"—psychodynamic versus behavioral perspectives being frequent competitors for this conceptual space—are, from this perspective, irresolvable. Both perspectives contain partial truths. Although highly innovative, perhaps even revolutionary in its comprehensiveness, the PGT approach has been implicit in graduate clinical psychology training. Whenever a question on a comprehensive examination has demanded that a student describe a case using more than one theoretical perspective for a client with a PD (i.e., the student could choose from among psychodynamic, client-centered, interpersonal, cognitive, family systems approaches, etc.), then an aspect of PGT was involved.

THE STATUS OF RESEARCH ON PERSONALITY-GUIDED THERAPY There is always tension about when to release scientific information. On the one hand, appropriate caution must be taken to show that a treatment has efficacy. On the other hand, to delay means that individuals who may benefit from a new treatment are denied that opportunity. PGT is a new treatment. Although its origins can be traced in various ways to Millon's writings over many years (e.g., Millon, 1969/1985, 1981, 1996), it was launched in 1999 with the publication of Millon's PersonalityGuided Therapy. To the extent that it is built on other approaches (such as cognitive-behavioral therapy, psychodynamic therapy, etc.), various aspects of the treatment are scientifically well established. It is fair to say that at this point, the treatment is in an exploratory phase, with a rich base of theory but with few empirical data. Case studies embedded in books on the topic are the only data extant that are specific to this approach (Everly & Lating, 2003; 8

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Farmer & Nelson-Gray, 2005; Harper, 2003; Magnavita, 2005; Millon, 1999; Rasmussen, 2005). Of course, as noted above, the long-term goal of the present endeavor is to lead to a manualized treatment with randomized clinical trials. Our approach is similar to that of Kernberg and his associates in the development of transference-focused psychotherapy. Initially, the group presented innovative treatment ideas based on psychodynamic theory and case material (O. F. Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Later, the treatment was manualized (Yeomans, Clarkin, & Kernberg, 2002) and subjected to a randomized clinical trial (Clarkin, Levy, Lenzenweger, & Kernberg, 2004).

A NOTE ON MEDICATIONS A number of medications are available to treat depression; these interventions are addressed in chapter 2. PDs per se cannot be treated with medications. However, underlying dimensions, such as impulsivity and psychoticism, are amenable to medication treatment. Medications for the relevant PD will be discussed in each chapter (chaps. 3-12). One study merits consideration here, because it addressed a mixed sample that included various PDs; to avoid repetition, I review the study here and allude to it briefly throughout the text. Ekselius and von Knorring (1998) examined 400 participants with major depression whom they randomly assigned to treatment with one of two antidepressants, sertraline or citalopram, both SSRIs. A 24-week course of treatment was completed by 308 participants (i.e., 145 with sertraline, 163 with citalopram), of whom 189 (61%) had a concurrent PD. No other treatments were provided (e.g., no psychotherapy). The researchers examined 10 PDs: paranoid, schizotypal, schizoid, histrionic, narcissistic, borderline, avoidant, dependent, obsessive-compulsive, and passive-aggressive, using a structured interview. The examiners reported that they excluded antisocial and self-defeating PDs, though they did not provide an explanation for this; they did not mention aggressive-sadistic PD. Although participants were randomly assigned the different medications, the study lacked a nontreatment control group. Because they used a structured interview pre- and posttreatment, the researchers had a dimensional measure (number of criteria met) and a categorical measure (whether the person had or did not have a disorder). In the sertraline group, there was a decrease in the number of PD criteria met for each one except schizoid. There was a decrease in the percentage of individuals diagnosed with PDs with both medications. In the sertraline group, paranoid, borderline, avoidant, dependent, and obsessive-compulsive PD criteria were less common posttreatment. (Schizoid diagnoses actually increased significantly, but this was accompanied by no significant change in number of criteria met, a finding that is admittedly difficult to reconcile.) In INTRODUCTION

9

the citalopram group, there were decreases in paranoid, histrionic, borderline, avoidant, dependent, and obsessive-compulsive diagnoses. Differences between the two medications were mostly nonsignificant, except that citalopram was superior to sertraline for obsessive-compulsive PD. Most other studies, which are reviewed in later chapters, looked at medication treatment for a single disorder. Ekselius and von Knorring's (1998) approach, to give a medication and measure the impact on a number of PDs, is somewhat more efficient, in that multiple comparisons can be made simultaneously (i.e., we can see that a medication has a positive effect on many PDs, with implications that a medication may be better for one disorder than another). The study is inconclusive, however, because there was no comparison group, so we do not know for sure what would have happened without treatment. Given the slow rate of spontaneous remission of PDs, and positive findings in controlled trials with SSRIs for borderline PD and social phobia (see chaps. 7 and 10, respectively), the most likely conclusion is that the medications had at least some effect. Effect size was not formally measured but appeared to be moderate. On average, there was a remission rate of approximately 25% ("any PD" went from 59.3% to 45.5% in the sertraline group and from 63.2% to 44.8% in the citalopram group). Remission rates exceeded 50% for borderline PD (either medication), dependent PD (either medication), and histrionic PD (citalopram). The decrease in the number of criteria met for each PD ranged from 0 to 1.3; the mean decrease was less than 0.5 for Cluster A, about 0.6 to 0.7 for Cluster B, and about 0.6 to 0.8 for Cluster C, depending on the medication. The largest change was for borderline PD (sertraline = -1.2; citalopram = -1.3). Using multivariate statistics, the authors illustrated that the decreases in PD symptoms were not a function of improvement in depressive symptoms. As will be illustrated throughout the remainder of this volume, however, medication research on PD populations constitutes a hodgepodge of case studies; open-label studies; and small, brief, randomized controlled trials. Although statistically significant effect sizes have been found with many medications for many problems associated with PDs, effect sizes are consistent with using medications in an adjunctive role. Noted Soloff (1997), Medication effects are modest, at best. GAS scores in the 1989 Soloff et al. haloperidol vs. amitriptyline trial improved 14 points, to an average of 55, in the most responsive group (HAL). Similarly, the average HAMD score fell from 26 to 16 in the HAL group, still symptomatic for most drug trials in depression, (p. 339) Even for borderline PD, which has been studied more than all other PDs combined, the research base is woefully inadequate (Soloff, 2000); how much more so for other PDs, many of which lack even a single empirical study? The lack of research on the use of medications for individuals with PDs is most unfortunate. Available studies suggest high rates of medication ]0

PERSONALJTY-G UIDED THERAPY FOR DEPRESSION

use in individuals with borderline PD (see Zanarini, 2004), and it is reasonable to speculate that individuals with other PDs also receive medication at rather high rates. The clinician should not complacently assume that medications that treat Axis I disorders are also beneficial for individuals with the Axis I condition in the context of a PD. A cautionary tale is the use of benzodiazepines and tricyclic antidepressants in the treatment of individuals with borderline PD; the limited available research suggests possible disinhibition and an iatrogenic increase in impulsive aggression following use of one or both of these classes of medications (see chap. 7). Understandably, studies that assess medications for their effect on depression usually exclude PD cases, but this strategy leaves us even deeper in the dark regarding the impact of antidepressants on individuals with a PD in conjunction with a depressive disorder. I join others in the field (e.g., Coccaro, 1998; Soloff, 2000) who have called for more research in the use of medications with individuals who have PDs.

THE STRUCTURE OF THIS VOLUME To develop an integrative understanding of depression and PDs, I first looked at the research on depression itself (chap. 2). Questions regarding the epidemiology as well as the effectiveness of current treatment modalities are explored. The chapter ends with a discussion of theoretical models of the relationship between PDs and depression; I implicitly draw on these models throughout the remainder of the text. Chapters 3 through 12 cover the relationship of depression to each of the 10 PDs of DSM-IV-TR. In each of these chapters, I begin with an illustration of the phenomenon, often drawn from the arts, film, or everyday experiences. Next, I cover theoretical and empirical material from a biopsychosocial perspective, leading to three major subsections. The biological section looks at hereditary factors, neuroanatomy, neurochemistry, and medications. The psychological section considers theoretical and empirical contributions from numerous important perspectives: psychodynamic, cognitive—behavioral, client-centered and humanistic, family systems, and group therapy, with a separate section on strengths-based conceptualization and intervention. The degree of coverage is based on the available literature, so some sections are brief or absent from some chapters. The social section includes considerations of diversity such as race and ethnicity, gender, socioeconomic status, and religion. Finally, a section on treatment planning, including a case example, illustrates the integration of the various perspectives into a personality-guided approach. The demographics of all case examples have been modified to protect the privacy of the clients. Many are composite cases, which combine elements of treatment for more than one client. At the end of the section on psychological approaches in chapters 3 through 12, I asked colleagues who contributed cases to share their insights INTRODUCTION

11

as well. I have integrated the findings of selected scientific studies and theoretical manuscripts. The studies were chosen because they are directly related either to depression or the specific PD under review. Because "countertransference" is conceptualized broadly for the present purposes (i.e., to include any emotional response of the therapist), it is included in its own section rather than subsumed within the psychodynamic area. It is beyond the scope of this book to look at PDs and depression in children. Some excellent resources are available in this regard. Paulina Kernberg and her associates have provided a well-reasoned approach with rich, illustrative case material (P. Kernberg, Weiner, & Bardenstein, 2000). In addition, the reader is directed to Stanley Greenspan's developmental, individual-difference, relationship-based model. Greenspan's approach to children, although developed in the context of autism, may have potential to treat children as early as infancy to prevent PDs, or to remediate PD symptoms in children. Greenspan noted how various kinds of rigidity in early childhood may "sow the seeds" for character pathology (1997, p. 322). Although these assumptions require further testing, I believe that Greenspan's approach has potential for any child who is tending toward a PD and urge the interested reader to examine one or more of Greenspan's writings (e.g., Greenspan, 1997; Greenspan & Wieder, 1998) and the Interdisciplinary Council on Developmental and Learning Disorders Web site (http:// www.icdl.com). Finally, Nadine Kaslow and her associates have done an excellent review on the status of various approaches to treating depression in children (Kaslow, McClure, & Connell, 2002). Each chapter is largely independent of the others. Chapters 3 through 12 are arranged alphabetically within each DSM-IV-TR PD cluster (i.e., Clusters A, B, and C). With the exception of the first two (i.e., this introduction and the overview of depression), concepts and data from which are woven throughout the book, the chapters draw content only minimally from one another. I recommend reading chapters 1 and 2 first, but thereafter chapters may be read in any order.

12

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

2 AN OVERVIEW OF DEPRESSION AND THEORETICAL MODELS OF ITS RELATIONSHIP TO PERSONALITY DISORDERS

Before describing the personality-guided therapy (PGT) approach to treatment, it is important to review current theories of depression, as well as the various established treatment modalities and their efficacy. In this chapter I describe the phenomenology and epidemiology of depression; then 1 enumerate the relevant treatment approaches according to the biopsychosocial model. Biological theories focus on the role of the neurotransmitter norepinephrine (NE) and serotonin in depression, and treatments include pharmacotherapy and electroconvulsive therapy (ECT). The psychological theories and interventions section considers cognitive-behavioral, interpersonal, psychodynamic, family systems, and group approaches. The section on social concerns addresses issues of diversity, such as gender, ethnicity, and socioeconomic status in understanding the person with depression. Next, I review possible relationships between depression and personality disorders (PDs) as enumerated by theory. These models of relationships, which attempt to sort out the chicken-and-egg relationship between Axis II 13

and Axis I psychopathology, are potentially useful in both research and clinical settings. For the researcher, understanding the various possible Axis I-Axis II relationships (e.g., whether a PD generally precedes a depression, or the converse) is of obvious theoretical interest, having implications not only for treatment but also for developmental theory as well as for possible refinements in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) taxonomy. Considering the possible relationships of depression to PDs (e.g., the possibility of lingering effects of one or the other disorder) may help the clinician to think more flexibly in understanding the client's perspective.

PHENOMENOLOGY OF DEPRESSION Depression, especially in its most severe form, can be an agonizing disorder. William Styron (1992) brought his literary genius to bear on the issue of his own depression in his memoir Darkness Visible. He noted, The argument I put forth was fairly straightforward: the pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain. Through the healing process of time—and through medical intervention or hospitalization in many cases—most people survive depression, which may be its only blessing; but to the tragic legion who are compelled to destroy themselves there should be no more reproof attached than to the victims of terminal cancer, (p. 33)

He later attempted to describe the nature of the pain itself: What 1 had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape form this smothering confinement, it is entirely natural that the victim begin to think ceaselessly of oblivion, (p. 50)

Finally, in a memorable quote regarding suicidal ideation, he stated, Yet in truth, such hideous fantasies, which cause well people to shudder, are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality, (p. 53)

14

PERSONALfTY-GL/IDED THERAPY FOR DEPRESSION

Although his rather supportive views on suicide are not likely to be widely shared in the mental health community—nor do I support them—Styron's compelling portrayal of major depression clearly conveys its agonizing quality. There are five forms of depression listed in DSM-IV-TR that differ in intensity; chronicity; and, to some degree, etiology. Major depression, the most severe form, is characterized by depressed mood much or all of the time as well as vegetative symptoms such as disturbance of sleep, appetite, and libido. Dysthymic disorder is similar to major depression but is of lesser intensity and is, typically, longer in chronicity. DSM-IV-TR requires a minimum of 2 years to make a diagnosis, though individuals can have the disorder for many years. Adjustment disorder with depressed mood indicates a reaction to an identifiable situation with depressed mood, in excess of what would be expected within a given culture. There are also two disorders in the appendix of DSMIV-TR, with criteria provided for research purposes. One is minor depression (similar to major depression but less severe), and the other is recurrent brief depression (with multiple depressive episodes that last from 2 to 13 days). The painful nature of depression is made all the more compelling when one considers its high frequency in the population. The problem of depression ripples out to families, businesses, and society at large. To understand the scope of the problem, the next step is to examine the frequency of the disorder; further, by looking at the financial cost of the problem, we can obtain a crude estimate of the overall impact of depression.

EPIDEMIOLOGY OF DEPRESSION The National Comorbidity Survey Replication (NCSR) used face-toface household surveys performed between February 2001 and April 2003. The nationally representative sample consisted of 9,282 English-speaking participants who were at least 18 years of age. In their sample, 16.6% had had major depression and 2.5% had had dysthymic disorder at some point in their lives. This translates into approximately 33 million people in the U.S. population who had experienced major depression, 6.6 million of whom had had major depression within the past year. Projecting out to the future, the researchers estimated that by age 75, 23.2% would have had major depression, and 3.4% would have had dysthymic disorder. The median age of onset for any mood disorder (including bipolar I and II, though these account for a relatively small proportion of those with mood disorders) is 30 years old, which is much older than that for anxiety disorders (11 years), substance use disorders (20 years), and impulse control disorders (11 years). Female gender and marital disruption are risk factors for major depression (Kessler, Berglund, Demler, Jin, & Walters, 2005).

AN OVERVIEW OF DEPRESSION

15

Depression rates appear to be rising. According to the original National Comorbidity Survey (NCS) conducted from 1990 to 1992 (Kessler, 1994), 15.8% of respondents met the criteria for major depression. It must be noted, however, that somewhat different criteria were used in the two studies, with the NCS using criteria from the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) and the NCSR using criteria from the fourth edition (DSMIV; American Psychiatric Association, 1994). Although the reported depression prevalence rates are quite high, Kessler et al. (2005) noted that the procedure used for the NCSR likely underestimated the actual prevalence of mental disorders. Interviews were done in a community setting, thereby eliminating some populations that are likely to have a high prevalence of disorders (e.g., the homeless or institutionalized). In addition, participants routinely underreport embarrassing behaviors. Lifetime prevalences were based on current risk factors; because the prevalence of mental illness is rising, it is likely that younger participants' lifetime risks were underestimated. The NCSR also demonstrated that depression is inadequately treated. The researchers found that only 56.8% of those with major depression and 67.5% of those with dysthymia received treatment of any kind; of those, only 37.5% (major depression) and 40.7% (dysthymia) received at least minimally adequate treatment (Wang, Lane, et al., 2005). Using evidence-based treatment guidelines, Wang, Lane, et al. (2005) defined minimally adequate treatment as appropriate medication prescription with at least four follow-up visits with a physician, or, for nonpsychotic patients, at least eight sessions with a psychiatrist or another mental health professional (e.g., a psychologist, social worker, or counselor). Overall, then, roughly three fourths of those who had depression did not receive even minimally adequate treatment. Those under the care of a mental health specialist (psychiatrist, psychologist, etc.) were far more likely to receive minimally adequate care than those under the care of a general medical doctor (52.0% vs. 14.9%). The comparable figures from the original NCS, which was conducted a decade earlier (1990-1992), indicate that only 45.8% received any treatment and that of these, 48.2% received minimally adequate treatment; thus, 78.2% failed to receive minimally adequate treatment for a mood disorder (Wang, Demler, & Kessler, 2002). Typically, there is a 6- to 8-year delay between the onset of symptoms and initiating treatment (Wang, Berglund, et al., 2005). For mental health disorders as a whole, there is a trend toward increasing treatment rates, but still only a minority of those with mental health problems receive services. In the 1980s, for example, estimates indicated that 19% of those with mental health disorders had received treatment in the past 12 months; the comparable figure was 25% in the 1990-1992 survey and 33% in the most recent survey, conducted in 2001-2003 (Wang, Berglund, et al., 2005). These disturbingly low figures are exacerbated when one con16

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

siders that fewer than half of those treated received minimally adequate treatment; for example, in the most recent survey, treatment was minimally adequate for only 32.7% of those receiving care for a mental health condition. The most underserved are older adults, racial and ethnic minorities, people with low incomes, the uninsured, and those who live in rural areas. Wang, Lane, et al. (2005) concluded tersely, "Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality" (p. 629). The estimated financial cost of depression as of 2000 totaled approximately $83 billion per year, an increase of nearly 8% from the 1990 estimate ($77 billion, inflation adjusted). The total figure for 2000 consisted of $26 billion (31%) for direct treatment expenses, $5 billion (7%) for costs associated with suicide, and a staggering $52 billion (62%) in workplace costs ($37 billion from absenteeism and $ 15 billion from reduced productivity while on the job; P. E. Greenberg et al., 2003). Even these enormous figures are an underestimate, because they do not account for accidents, turnover, or the impact on coworkers. Simulations have indicated that 45% to 90% of direct treatment costs are recovered in a single year through worker productivity gains; it is reasonable to expect that all of the treatment cost, or perhaps even more, could be recovered if a longer window were used (Kessler, 2002).

THEORIES OF DEPRESSION AND THEIR ASSOCIATED TREATMENTS How does a person become and remain depressed? And how does he or she recover? Biological, psychological, and social factors are essential in gaining a comprehensive understanding. Starting with the smallest unit of analysis, I explore biological factors such as neurochemical and neuroanatomical phenomena. Moving outward to a broader domain, I examine psychological aspects of depression, including intrapsychic and interpersonal manifestations. Finally, at the macro level, I integrate societal and cultural issues, such as gender role and ethnicity. Biological Factors There is a significant genetic component to depression. Sullivan et al. (cited in Wallace, Schneider, & McGuffin, 2002, pp. 174-175) conducted a review and meta-analysis of twin studies on major depression. Over 212,000 individuals were studied. Results indicated that 58% to 67% of the variance was attributable to specific environmental effects, 31% to 42% to genetic factors, and a mere 0% to 5% to shared environment among siblings. According to Thapar and McGuffin (cited in Wallace et al., 2002, p. 177), AN OVERVIEW OF DEPRESSION

17

heritability estimates (the degree to which a trait is inherited) 1 were higher (79%) for children and adolescents, which suggests that when depression starts early in life it may be a more biological condition. The largest and best available adoption study, by Wender et al. (cited in Wallace et al., 2002, p. 176), indicated a sevenfold higher likelihood of depression among those who were biologically related to a depressed person versus those who were not. A variety of biological factors are critical in depression. Under stress, NE becomes depleted, which has been associated with learned helplessness behaviors in animal studies (e.g., decreased exploratory and consummatory behaviors) and is believed to be related to learned helplessness cognitions in humans (e.g., powerlessness and hopelessness). Medications that directly enhance NE levels lead to improved functional efficiency. It is interesting to note that serotonin'enhancing medications (which do not directly effect NE) also enhance NE levels, suggesting that indirect interventions can help restore NE balance. Because of the popularity of SSRI medications, most psychologists are aware that serotonin (5-HT) depletion also increases depressive symptoms. The hypothalamic-pituitary-adrenocortical (HPA) axis, which mediates human stress responses such as the fight—flight response (W. B. Cannon, 1915, 1929/1963) and the general adaptation syndrome (Selye, 1956/1978), is also implicated in depression. Sustained elevations in cortisol lead to impaired HPA feedback inhibition and can cause the death of cells in the hippocampus. In samples of depressed individuals, 40% to 60% have elevated levels of cortisol. Increased dopamine activity, which may be induced by excessive cortisol, appears to be crucial in cases of psychotic depression (Thase, Jindal, 6k Rowland, 2002). Excess cortisol is associated with increased severity of depression, weight loss, insomnia, and increased suicidality (Thase et al., 2002). Research has yet to determine, however, if these biochemical changes cause depression or are a result of it. It is probable that causality is complex and circular; it seems reasonable to assume that similar to the relationship between temperament and the development of PDs, biological predispositions interact with environmental circumstances, enhancing or initiating biological processes related to depression. In addition, if depleted NE and serotonin are sufficient to explain the occurrence of depression, then why do antidepressant medications take weeks to produce mood changes, even though neurotransmitter levels are increased within hours (Thase et al., 2002)? Although the mechanism of action of the medications described below is presented using explanations based on neurotransmitter theory, along the lines of standard psychopharmacology texts (e.g., Stahl, 1996), the reader should be aware that there are other, and at this point unknown, reasons for the efficacy of antidepressant medications. 'The most common metric, labeled h2, is based on the difference between the frequency of a trait in fraternal versus identical twins.

18

PERSONALITY^ HIDED THERAPY FOR DEPRESSION

Medications A variety of medications have been shown in double-blind studies to ameliorate depression, (e.g., I. M. Anderson, 1998; Rudolph, 2002; Storosum et at, 2001). Historically, the first antidepressant medications developed were monoamine oxidase inhibitors (MAOIs). Drugs formerly used to fight tuberculosis were found to have an unexpected antidepressant effect. Scientists then isolated the effective compound and formulated the medications specifically as antidepressants. This discovery led to the first biological theory of depression, the monoamine hypothesis. The theory was that depletion of monoamines leads to depression. This was supported not only by the action of MAOIs (which, as their name implies, block the action of monoamine oxidase, the enzyme that breaks down monoamines, a group of neurotransmitters that include serotonin and NE, and increase the availability of monoamines) but also by findings that drugs that reduced the amounts of monoamines lead to depression (Stahl, 1996, p. 112). MAOIs, then, work by blocking the action of (inhibiting) monoamine oxidase. With less monoamine oxidase breaking down monoamines, more monoamines are available to the neurons. This increase in monoamines, the theory indicates, decreases depression. Widely used MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). Tricyclic antidepressants (TCAs) are so named because the original medications had a three-ringed chemical structure. As with MAOIs, the antidepressant qualities of TCAs were discovered while they were being used to treat another disorder, in this case schizophrenia. Though the medication was ineffective for schizophrenia, clinicians noticed during the clinical trials that their patients were becoming less depressed. TCAs quickly became popular because they were effective and the side effects were not as troublesome as those of the MAOIs. Tricyclics are still widely used but are declining in popularity because SSRIs tend to have fewer side effects. Most TCAs are available in generic form and are relatively inexpensive, which can be a big advantage in some circumstances. TCAs work by blocking the action of the reuptake pump for serotonin and NE. Because the neurotransmitters are not reabsorbed by the neurons, they remain in the synapse, the space between neurons. (Neurotransmitters leave a neuron, enter the synapse, and potentially cause the next neuron to fire.) The extra neurotransmitters in the synapse, per the monoamine hypothesis, lead to a decrease in depression. Common tricyclic compounds include amitriptyline (Elavil), desipramine (Norpramin), doxepin (Sinequan), and imipramine (Tofranil). With SSRIs, the basic mechanism of action is to block the reuptake (reabsorption) of serotonin back into the neurons, thereby leaving more serotonin available in the synapse. As with TCAs, the increased availability of synaptic monoamines underlies the antidepressant effect. SSRIs and other newer antidepressants are generally used first because of their improved side-

AN OVERVIEW OF DEPRESSION

19

effect profile relative to the older TCAs. Commonly used SSRIs include citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). A number of relatively new antidepressants do not fit conveniently into any of the previous three categories (MAOI, TCA, or SSRI) and impact serotonin and NE through various mechanisms of action. Drugs in this "novel" category include amoxapine (Asendin), bupropion (Wellbutrin), maprotiline (Ludiomil), venlafaxine (Effexor), mirtazapine (Remeron), nefazodone (Serzone), and trazodone (Desyrel). Antidepressant medications have generally been found to have approximately equivalent effects on symptoms as short-term psychotherapy, with combinations of psychotherapy and antidepressant medications generally having somewhat improved efficacy (I. W. Miller & Keitner, 1996). For longterm relapse prevention, it is now known that long-term medication maintenance is often required (Gitlan, 2002). Antidepressants typically take several weeks to alleviate symptoms, although elevated levels of serotonin are available in the synaptic cleft within a few hours. Scientists have concluded that the effects of antidepressants occur as a function of complex interactions at the intracellular level. Thase et al. (2002) noted, "It is now clear that the synaptic effects of the TCAs, MAOIs, and newer antidepressants only serve to initiate a sequence or cascade of effects that culminate within cell nuclei, at the level of gene activity" (p. 201). A detailed explanation of mechanisms of action is beyond the scope of this review, but the curious reader is encouraged to peruse Stahl (1996) and Gitlan (2002). SSRIs are currently the frontline pharmacotherapy for depression in the United States. Their relatively benign side-effect profile and easy, usually once-daily, dosing encourages high compliance. Equally critical, and more so in some cases, SSRIs have much lower lethality than TCAs in overdose and are thus difficult to use as instruments of self-destruction. If one SSRI is ineffective or cannot be tolerated, most prescribers will switch to another SSRI and then, if necessary, to another drug class. The "novel" antidepressants all have different chemical structures, properties, and side-effect profiles; in essence, each is its own drug class. Some of these medications are sedating (e.g., nefaxedone and trazedone) and they may also encourage weight gain (e.g., mirtazepine), which can be therapeutic in cases that include insomnia and anorexia. The older tricyclic medications are rarely firstline medications because of unpleasant side effects (e.g., dry mouth, sedation, postural hypotension, weight gain, blurry vision, and constipation) and high lethality in overdose. They may be prescribed when cost is a consideration and, of course, when other medications have been ineffective. MAOIs are generally a third- or fourth-line treatment because of unpleasant side effects (e.g., weight gain, sexual problems, and insomnia) and dangerous interactions with foods that contain tyramine (e.g., wines and aged cheeses). Although better known 20

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

for treating bipolar disorder, lithium can be useful in some cases of unipolar depression. It tends to be used rarely because of its narrow therapeutic window and its toxicity, and, thus, the requirement for routine blood work. Dysthymic disorder responds to medications in a way that is essentially identical to major depression, so the above considerations apply to both equally (Gitlan, 2002). Electroconvulsive Therapy ECT has been considered a safe and effective treatment for depression for nearly 2 decades (American Psychiatric Association, 1990; Enns & Reiss, 2001; National Institutes of Health, 1985; Pagnin, de Queiroz, Pini, & Cassano, 2004; UK ECT Review Group, 2003). Understandably, there are fears among some in the general public. The idea of passing an electrical current through the body can be frightening; further, popular depictions of the inappropriate use of ECT and images of the procedure prior to the introduction of adequate sedative medication may enhance the concerns of a potential beneficiary. Ken Kesey's One Flew Over the Cuckoo's Nest (1962/2002) and its extraordinarily popular film adaptation (Zaentz, Douglas, & Forman, 1975) portrayed ECT (without sedation) as a punishment—or even torture— used against a spirited and nonconforming patient. Such images may frighten potential patients who could benefit from an appropriate use of ECT. Psychoeducation for the client and, potentially, the family, is extremely important in cases in which ECT is the best option. Memory problems are the main side effects associated with treatment (American Psychiatric Association, 1990). For severe depressions in which several medications have been ineffective, ECT remains an important intervention. Summary and Conclusions Regarding Biological Factors Biological factors play an important role in depression. The disorder is heritable, and a number of biological models of depression have considerable scientific support. Nonetheless, those who argue that depression is a purely biological "disease" and that the best treatment is medication are flying in the face of a massive amount of data. Current scientific studies cannot validate any of the proposed biological models (e.g., serotonin depletion) as causes of depression; rather, they may be effects. As noted above, genetic studies have shown that nearly twice as much variance is accounted for by environmental factors as by genetic ones. Medication has not proved to be better than psychotherapy for treating depression; in fact, overall, studies seem to suggest that for all but the most severe depressions, psychotherapy has better efficacy (American Psychiatric Association, 2000b). Despite the existence of several classes of medications and several medications within most classes, approximately 35% to 40% of individuals do not respond to medication treatment. Data are fairly consistent with the commonsense hypothesis that psychotherapy and medications work synergistically (I. W. Miller & Keitner, AN OVERVIEW OF DEPRESSION

21

1996) and that long-term follow-up with medications and psychotherapy help prevent relapse, which is otherwise likely (Boland & Keller, 2002). Gitlan (2002), summarizing his review of psychopharmacological treatment of depression, concluded, Although antidepressants are consistently effective and the newer agents are safer and better tolerated than the older agents, the pharmacotherapy of depression still leaves much to be desired. As a first goal, it must be acknowledged that no antidepressant has been shown to be more effective than imipramine, the first agent released over 40 years ago. (p. 377) Psychological Factors Millon (1996) listed eight domains of functioning that should be considered when making a comprehensive psychological assessment, namely (a) expressive acts, (b) interpersonal conduct, (c) cognitive style, (d) selfimage, (e) object representations, (f) regulatory mechanisms, (g) morphological organization, and (h) mood and temperament. These domains roughly correspond to the major "orientations" within psychology. Expressive acts and cognitive style relate to the cognitive-behavioral school of thought. Interpersonal conduct is most closely associated with interpersonal and family systems thinking and interventions. Self-image—how one sees oneself—is relevant to all therapeutic schools of thought but is perhaps most closely associated with a client-centered approach. The next three domains are associated with psychodynamic thinking. Object representations relate to object relations theory, and regulatory mechanisms refer to Freud's ego defense mechanisms. Morphologic organization, which refers to psychic cohesion within the mind, is most closely associated with self psychology and the notion of fragmentation (Kohut, 1971, 1977; Wolfe, 1989). Finally, the mood and temperament domain refers primarily to the biological components of emotionality (mood) and personality traits (temperament). The psychology subsections of the remaining chapters in this volume cover Millon's domains, with some variations depending on the relevance to particular disorders. Of the eight domains, seven are psychological, and one is biophysical. Each of the psychological domains are considered with reference to cognitive-behavioral; client-centered, humanistic, experiential; psychodynamic; family systems; and group therapies. Below I discuss each in turn. Cognitive-Behavioral Conceptualization and Interventions Beck and his associates noted that depression is related to cognitive distortions (A. T. Beck et al, 1979). Cognitive distortions are styles of thinking that reliably produce problematic, depressogenic thoughts. For example, overgeneralization is the tendency to see one event as more representative than it really is (e.g., I'm incompetent at one thing, which means I'm incom22

PERSONALITY-GLTOED THERAPY FOR DEPRESS/ON

petent at everything). Dichotomous thinking, which is especially relevant to borderline PD, is the tendency to view everything in all-or-none terms (e.g., I'm either perfect or I'm worthless). Catastrophizing is the tendency to interpret events as being much more problematic than they really are (e.g., the student who becomes suicidal when she earns her first C; her thoughts may be, "Now I'll never get into graduate school, I'll never get a good job, and my parents will hate me"). When such thought patterns are corrected, then the depression tends to lift. Individuals with depression are likely to have a variety of depressogenic thoughts. Common thoughts among individuals with depression are, "If I try to do it, I'll just mess up"; "If I ask her out, she'll turn me down"; and "No one likes me." Underlying such automatic thoughts, especially for individuals with PDs, are core beliefs of helplessness, unlovability, and worthlessness (J. S. Beck, 2003). Often, feelings of worthlessness are reducible to one or both of the other two categories (e.g., I am worthless because I am incompetent and/or unlovable). Schemas of helplessness fit with Seligman's wellknown and well-established learned helplessness model, which can be conceptualized in a purely behavioral fashion (Seligman, 1975), and the reformulated version (Abramson, Seligman, & Teasdale, 1978), which includes helpless cognitions. In addition to the belief "I am helpless," clients may express this concept with beliefs of inadequacy, incompetence, and inferiority. The belief that one is unlovable relates to poor self-esteem and is clearly related to depressive thinking; typical core beliefs may include "I am unlovable," "I am ugly/undesirable," and "I am unwanted." A variety of behavioral interventions can also be helpful in alleviating depression. Communication skills training and assertiveness training can help clients to get their needs met more effectively. Linehan (1993) framed mindfulness meditation as a learned skill and made it a module in her dialectical behavior therapy program. In some cases, skills training can be used to help the person feel—and be—more competent, thus undermining feelings of helplessness. Physical exercise has been shown to relieve depression (Craft & Landers, 1998; Hays, 1999) and has obvious health benefits. The clinician, however, must suggest an exercise program very astutely or the chances of success are minimal. Unless the client neither watches television nor reads newspapers, he or she has undoubtedly been bombarded by messages about why we should all be exercising more. A generic, information-based approach about the benefits of exercise generally will not lead to behavior change. At best, a half-hearted "I know I should exercise more" will emerge; in such an instance, the therapist is risking being seen as an authority figure who is disappointed with the client's performance. Instead, it is essential to focus extensively on motivation. I generally do not even broach the subject of exercise for several sessions, sometimes many sessions. I like to see the depression lift partially so that I have some credibilAN OVERVIEW OF DEPRESSION

23

ity built up and motivation is not quite so difficult for the client to muster. When I do bring up exercise (unless the client does first), the discussion is embedded in the context of the client's goals. Perhaps the client's goal is to feel better, physically or emotionally (many are not aware that exercise has proven antidepressant effects, so psychoeducation can be helpful in such cases). Perhaps he or she has a goal of being healthier for another person. Often, weight loss is a goal. I have clients write down their goals and why exercise would help. Once the motivations are clear and adequate—if the motivation is not adequate, then we defer—then we can discuss specific strategies, such as the type of exercise and how that fits into the client's goals and needs. Prochaska's "stages of change" model (Prochaska et al., 1994) is extremely useful for assessing whether the client is ready for an exercise program. For the precontemplator who has no interest in an exercise program, the therapist can provide information that exercise helps depression lift and that at some point it would be useful to consider an exercise program. For the contemplator, more in-depth discussion can help the person to become aware that exercise may be worth it. During the preparation phase, one can develop specific strategies with the client, such as selecting the exercises to use, scheduling workouts, and discussing preference for exercising alone or with others. During the action phase, continued focus on motivation will remain important. Strategies such as making charts of progress toward a goal (e.g., losing a certain amount of weight or walking a certain number of miles) can be very motivating. Setting goals such as walking, running, or biking for a cause near to the person's heart can also be a great motivator; for example, setting a goal of completing a 5-mile walk for breast cancer can be motivating if the client knows someone who has or had the disease. There are books available for adjunctive bibliotherapy for exercise (e.g., Exercising Your Way to Better Mental Health, Leith, 1998; Move Your Body, Tone Your Mood: The Workout Therapy Workbook, Hays, 2002). Outcome data show clearly that cognitive-behavioral therapy (CBT) is effective. Over 80 research studies have shown that CBT is superior to placebo treatment, and it is superior to medications for all but the most severe depressions (American Psychiatric Association, 2000b). The Interpersonal Approach Coyne (1976) proposed an interactional model of depression. In contrast to work by psychodynamic theorists (e.g., Abraham 1911/1986; Freud, 1917/1986) and Beck's emerging cognitive theory (e.g., A. T. Beck, 1967), Coyne emphasized people's accurate perceptions rather than their distortions. He observed that depressed individuals have a tendency to seek reassurance. Initially, caring others in the environment wholeheartedly provide such reassurance. However, convinced that these individuals are responding

24

PERSONALITY^ HIDED THERAPY FOR DEPRESSION

to his or her manipulations, the person with depression persists. Other people eventually become annoyed and send mixed messages; they provide comfort, but, in contrast to their prior, genuine encouragement, they are at least in part responding only to the demands for reassurance. A vicious circle ensues, in which demands for reassurance are met with increasing, but hidden and explicitly denied, annoyance on the part of the significant others while the person with depression becomes increasingly frustrated and perhaps hostile. As opposed to fantasized or early object loss, as emphasized by Freud, many people in the person's life are genuinely avoiding him or her in the present. If intervention occurs at this point, there is a mixture of cognitively distorted perceptions of worthlessness and accurate perceptions of real abandonment and insincerity within the depressed person's social network. The "excessive reassurance seeking" hypothesis has received research attention over the years and has generally been supported (Benazon, 2000; Coyne & Downey, 1991; Joiner, 1994; Potthoff, Holahan, & Joiner, 1995; Swann, Wenzlaff, Krull, & Pelham, 1992). Similar to Coyne, and building on themes developed by Harry Stack Sullivan and other theorists, Gerald Klerman, Myrna Weissman, and their associates developed interpersonal psychotherapy (IPT) in the 1970s (Weissman & Markowitz, 2002) as a time-limited treatment for major depression. Outcome data for IPT have been impressive; the treatment has consistently been better than placebo, has been about as effective as cognitive-behavioral therapy for most clients, and has been more effective than CBT for more severely depressed patients (for a review, see Weissman 6k Markowitz, 2002). IPT uses an unabashedly medical model approach to treatment: "In IPT, depression is defined as a medical illness, a treatable condition that is not the patient's fault" (Weissman & Markowitz, 2002, p. 406). This approach helps to reduce guilt and feelings of inadequacy on the part of the patient and facilitates a natural alliance of client and therapist against the depressive symptoms. IPT focuses on interpersonal problems in the person's current life, such as complicated bereavement, role transitions, and interpersonal deficiencies. The therapeutic relationship is designed to be positive, optimistic, and collaborative. Relatively little transference distortion is elicited in this approach, and investigation of transference phenomena is not routinely part of the treatment. The IPT therapist assists clients in pursuing their interpersonal goals. Events in clients' lives are consistently linked to their mood and symptoms. Emotionally intense events in their interpersonal lives are reenacted and role-played, and options for making different kinds of choices are considered. The treatment is designed to be brief and typically takes approximately 12 to 16 sessions. Monthly follow-up sessions provide some protection against relapse, although Weissman and Markowitz (2002) suggested that biweekly relapse prevention sessions may be more effective and should be researched.

AN OVERVIEW OF DEPRESSION

25

Client-Centered, Humanistic, and Existential Therapy Process-experiential therapy (PET) helps individuals with depression by providing them with an opportunity to focus on their internal experience. The therapeutic relationship is characterized by empathic attunement and collaboration. Although the therapist and client collaborate on goals, the relationship issues are always considered primary. Noted L. S. Greenberg, Watson, and Goldman (1998), "A form of synchrony occurs where the experience of leading and following disappears in a collaborative flowing together, as in good dancing or improvisational jazz" (p. 234). L. S. Greenberg et al. (1998) described four markers of problematic experiential states that are useful in understanding and treating depression. The first is problematic reactions, or a feeling of being puzzled by one's own emotional or behavioral responses to situations. The second is an inability to get a clear sense of one's experience. The third is a split sense of self, in which one part of the self is critical of or coercive toward the other part. Finally, individuals with depression often have "unfinished business" related to an earlier part of their lives, usually involving themes of separation, loss, or other unresolved issues. The inability of a person to get in touch with his or her own experience is treated with empathic attunement and encouragement to focus on his or her experience. The felt sense (Gendlin, 1996) is often a key concept in this regard and refers to subtle emotional and bodily experiences that can be used as doorways to deeper aspects of the self. The felt sense is something that we all experience. A good example is "that feeling that I forgot something," which, if examined even superficially, is a bodily and cognitive experience integrating thoughts ("I forgot something" and "this is bad") with somatic phenomena (e.g., a tightening in the abdominal muscles and a churning feeling in the stomach). In individuals with depression, the felt sense that something is wrong can be explored, often leading to the uncovering of feelings and thoughts that have been deeply buried under years of neglect or the exploration of thoughts and feelings that were regarded as too frightening to consider. Splits in the self, such as the critical self that berates the bad self, can be integrated using "two chair" techniques. The critical self can speak to the "bad" self, which can then, by switching chairs, answer back. Typically, the critical self can be seen for what it is—a cruel, narrow-minded bully who does not take the full picture into account. The "bad" self, meanwhile, is generally the holder of kindness, softness, and compassion and is seen to have good qualities. As the split between good and bad becomes transmuted into a split between aspects of the self that are all necessary for a completely functioning individual, the path to reintegration has been paved. L. S. Greenberg et al. (1998) described the case of "Jan," a highly self-critical, perfectionistic, and depressed woman who had unfinished business around

26

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

trying to please her mother. An initial reintegration occurred in rather dramatic fashion during a two-chair interaction: Therapist:

What do you want from her (to the critic) ? [Encouraging expression of need]

Client:

I want to feel I am OK. I want to be more like her, to feel more confident.

Therapist:

[Noticing a shift in her posture and face] What are you feeling now? [Facilitating negotiation]

Client:

1 feel that the two sides have suddenly merged. It is as if the stronger person came over here and sat with me and said you're OK. (p. 245)

Unfinished business, similarly, can often be addressed through "empty chair" techniques, in which the client addresses the individual who is no longer available. L. S. Greenberg et al. (1998) argued that PET benefits from looking at aspects specific to depression rather than maintaining a strict antilabeling stance: One might. . . question the need for a differential treatment of depression, given that a therapeutic relationship characterized by attitudes of positive regard and genuine concern, as well as a form of responding that is empathic and experience centered, is helpful for different types of problems and diagnostic groups. . . . We have observed both in practice and research contexts that, during treatment of depressed people, specific types of in-session problem states or markers of underlying determinants come up more often or with greater significance, and these are embedded within specific types of depressive themes. More specifically, we found that selfcritical splits, embedded within themes of failure and lack of self-esteem, and a variety of types of lingering unresolved feelings or unfinished business with significant others, embedded within themes of dependence and loss, characterize the in-session issues that formed the focus of our treatments of depression, (p. 229)

Congruent with cognitive therapy, L. S. Greenberg et al. (1998) observed that people with depression have beliefs that they are worthless, powerless, and bad and that they experience feelings of helplessness. As with Beck's notion of "core beliefs" that are activated by current experiences, L. S. Greenberg et al. noted, "In our model, the core depressogenic weak/bad self-scheme is activated by a current emotional experience of loss or failure" (p. 232); such a notion also relates to self-psychological notions that psychopathology emerges from a damaged sense of self. Similar to the interpersonal school, they noted that social disruptions and losses elicit depressive mood. PET differs from other approaches in its focus, like all humanistic and client-centered approaches, on the natural holistic and organismic aspects of the person. The therapist focuses not only on verbal and cognitive schemas but also on bodily

AN OVERVIEW OF DEPRESSION

27

sensations such as the felt sense of an experience and subtle emotional experiences that are difficult to label. The primary mode of intervention, which is to remain empathically attuned and promote the client's attention to his or her moment-to-moment experience, differs from other approaches. Research on humanistic psychotherapy for depression has been encouraging. There is a growing body of literature on PET. Elliott, Watson, Goldman, and Greenberg (2004) reviewed 18 research studies on PET, 6 of which addressed depression. All 6 of the studies reported a positive impact on depression, with effect sizes ranging from 0.50 to 2.49 standard deviations, which represent a medium to very large effect; the mean effect size is 1.36, which is large (see Cohen, 1988). To put these findings in perspective, a brief discussion of effect size is in order. Cohen (1988) noted that an effect size of 0.8 is sufficiently large to be obvious, such as the difference, for example, between the heights of 13- and 18-year-old girls. Seen another way, a difference of this magnitude indicates that 85% of those treated are better off than those who are untreated. Three of the studies were randomized trials comparing PET to other therapies (person-centered in two studies, CBT in the third). In all three cases, PET was superior to the other conditions (a mean difference of 0.38 standard deviations, a medium-sized difference). On the basis of these studies, PET qualifies as an empirically validated treatment for depression. Ward et al. (2000) conducted a fairly large (N = 464) randomized study of client-centered counseling, CBT, and routine physician care for depression. Participants were provided with 6 to 12 sessions of psychological treatment. The study demonstrated that both psychotherapies resulted in greater reductions in depressive symptoms and more rapid remissions in depression than routine physician care, but the therapies did not differ in effectiveness from one another. Psychodynamic Therapy Psychodynamic psychotherapy is the oldest form of psychological treatment, dating back approximately 100 years. In his essay "Mourning and Melancholia," Freud (1917/1986), in his astute manner, compared the phenomenon of normal grief to the state of melancholy that we now call depression. Before considering this comparison, it is worth noting that Freud's description of melancholia, which included feelings of dejection, poor self-esteem, loss of sex drive, and appetite and sleep disturbance, was in its essence identical to a description of major depression. In addition, Freud believed that some depressions were "constitutional" (biological) and did not abide by the psychic mechanisms he described. Freud noted that melancholia differed from grief primarily in the selfdenigration and self-esteem problems of the individual with this condition. Rather than arguing, as Aaron T. Beck did later (A. T. Beck et al., 1979), that such beliefs are irrational and problematic, Freud indicated that these self-attacking statements contain more than a grain of truth: 28

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

He also seems to us justified in certain other self-accusations; it is merely that he has a keener eye for the truth than other people who are not melancholic. When in his heightened self-criticism he describes himself as petty, egoistic, dishonest, lacking in independence, one whose sole aim has been to hide the weaknesses of his own nature, it may be, so far as we know, that he has come pretty near to an understanding of himself; we only wonder why a man has to be ill before he can be accessible to a truth of this kind. (Freud, 1917/1986, p. 51) With this rather backhanded compliment, Freud thus anticipated the "depressive realism" hypothesis by many years. Freud then rioted, however, that the attack on the self is invariably an attack on others, which is then redirected toward the self. The wife who proclaims that she is unworthy and cannot imagine how her husband would stay with her is really indicating her anger toward her husband and suggesting that he is inadequate in some unspecified manner. Abraham (1911/1986) extended the argument, seeing depression as a combination of defenses against underlying sadistic hostility. He suggested that the conscious experience ("I hate myself) consists of hostile feelings transformed through projection ("I hate you" becomes "you hate me" and, finally, "you hate me because I am defective"). As he noted, "In every one of these cases it could be discovered that the disease proceeded from an attitude of hate which was paralysing the patient's capacity to love" (1911/1986, p. 36). Freud hypothesized, in a rather tentative manner, that the constellation of phenomena thus observed in depression pointed to a coherent developmental pattern. He suggested that the person experiences a loss of love. Rather than withdrawing libidinal energy and attaching it to a new object, the ego withdraws the libidinal energy into the self, the narcissistic ego. The energy is then used to form an identification between the ego and the lost object. This transformation, then, is regressive in its essence; specifically, the regression is to the oral-sadistic phase, in which the merger with the object is accomplished through incorporation. This explains not only the primitive aggression associated with depression but also the phenomenon of suicide. Because the individual is identified with the object of his rage, it is possible for him to consider his own, or "its" (i.e., the object's) destruction. As noted by Freud, It is this sadism alone that solves the riddle of the tendency to suicide which makes melancholia so interesting—and so dangerous. So immense is the ego's self-love, which we have come to recognize as the primal state from which instinctual life proceeds, and so vast is the amount of narcissistic libido which we see liberated in the fear that emerges to a threat to life, that we cannot conceive how that ego can consent to its own destruction. We have long known, it is true, that no neurotic harbours thoughts of suicide which he has not turned back upon himself from murderous impulses against others.... The analysis of melancholia now AN OVERVIEW OF DEPRESSION

29

shows that the ego can kill itself only if, owing to the return of the object cathexis, it can treat itself as an object—if it is able to direct against itself the hostility which relates to an object and which represents the ego's original reaction to the external world. (Freud, 1917/1986, pp. 56-57) Thus the blurred identification between the self and the object, which is a function of the regression to a very early stage of life, allows the self to become a target of "murderous," that is, self-destructive, impulses. Thus the themes of anger turned inward, and the precursors of the depressive realism hypothesis, are present in Freud's early work on depression. Unfortunately, the empirical data supporting the psychodynamic view of depression (e.g. group designs and controlled studies) are limited (Coyne, 1976; Hollon, Thase, & Markowitz, 2002). Nonetheless, the rich history of theory and case studies is a deep well of clinical wisdom and has strongly influenced the field. Family Systems Therapy The relationship between marital problems and depression is substantial. According to a meta-analysis by Whisman (cited in Beach 6k Jones, 2002, p. 423), the correlation between depression and marital quality was -.66. Family theorists generally focus on the bidirectional nature of causality, noting that depression creates stress in the relationship and stress worsens depression, thus setting off a downward spiral. There are well-established marital and family treatments for depression using behavioral marital therapy, cognitive—behavioral marital therapy, emotion-focused therapy, and insightoriented marital therapy (for a review, see Baucom, Shoam, Mueser, Daiuto, & Stickle, 1998). According to studies by Patterson and by Patterson, Reid, and Dishion (both cited in Beach & Jones, 2002, p. 426), parent management training is effective for childhood depression. Interpersonal therapy, reviewed above, has been modified for use with couples and is called "conjoint marital therapy" (see Foley, Rounsaville, Weissman, Sholomskas, & Chevron, cited in Beach & Jones, 2002, p. 428). Available evidence suggests that the effect of marital therapy on depression is equivalent to that of individual therapy (but no better); however, it reduces marital distress more than individual treatment (Beach 6k Jones, 2002). In studies in which marital distress was not an issue, marital therapy did not confer any measured advantage. Thus, the evidence is consistent with the commonsense conclusion that marital therapy should be used in cases in which there is marital distress as well as depression; if there is no marital distress, then in most cases it would be more convenient for the depressed person to enter individual treatment. Parent training decreases symptoms in depressed children and in depressed parents simultaneously. If parent-child relationships are contributing to family stress or depression, it is an important treatment. In addition, 30

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

parent training may be a less threatening way to enter treatment for families in which there are both marital distress and parent-child problems (Beach & Jones, 2002). Group Therapy A meta-analysis of 48 studies of group psychotherapy (McDermut, Miller, & Brown, 2001) showed that group psychotherapy has a substantial impact on depression. The overall effect size of treatment is 1.03; that is, the treatment group, on average, had scores 1.03 standard deviations lower than corresponding control groups, which is a large effect size. The efficacy of group treatment of depression is comparable to that of psychotherapy in general (effect size = 0.68; M. L. Smith & Glass, 1977) and individual psychotherapy for depression (effect size = 1.22; Steinbrueck, Maxwell, & Howard, 1983). CBT (e.g., Kush, 2000; Peterson & Halstead, 1998; Pidlubny, 2002) and IPT (see Klier, Muzik, Rosenblum, & Lenz, 2001; MacKenzie, 2001) have been adapted to group modalities. It is most likely that a combination of factors within the group process combine to reduce depression. Individuals can acquire new skills, such as assertiveness or problem solving, which can help them function more effectively. Cognitive-behavioral groups help clients learn to challenge their irrational or distorted beliefs. Process-oriented groups help the person to confront relationship issues in the here-and-now, a very powerful form of learning. Other available group therapies for depression include multimodal therapy (Rice, 1995), narrative therapy (Laube & Trefz, 1994) and reminiscence therapy (Bachar, Kindler, Schefler, & Lerer, 1991). Few comparisons have been performed contrasting different types of therapy. One study (Hogg & Deffenbacher, 1988) found that process group therapy and CBT were equally effective in reducing depression, and no differences were found in mechanisms of action. Group therapy has several advantages relative to individual therapy. In skills-training groups, there are opportunities to practice with peers rather than just with the therapist. In addition, during the presentation of new information, others in the group may think to ask questions that an individual may not have thought to ask. In process groups, opportunities arise that cannot occur in individual therapy, such as feedback from multiple individuals simultaneously. Perhaps the primary advantage of group psychotherapy is that it provides similar efficacy at a lower cost. Estimates suggest that group psychotherapy saves 25% to 92% of the cost of care relative to individual therapy, depending on the size of the group (see McDermut et al, 2001). Of course, group therapy is not always preferable. Individual treatment offers greater privacy, which may allow some clients to open up more. It also may help to prepare clients for group treatment. Although McDermut et al. (2001) concluded, logically, that group therapy should be the frontline treatment for depression on the basis of cost considerations, for clients with PDs exactly the reverse may be true. Many individuals with personality disorders AN OVERVIEW OF DEPRESSION

3]

are not ready for group treatment until their symptoms have partially remitted. For example, clients with paranoid and avoidant PD are often too interpersonally defensive and uncomfortable to function in a group; some individuals with narcissistic PD are unable to share attention with other group members; some individuals with schizotypal PD would come across as so strange that the group would reject them, furthering their depression. For many individuals with PDs and depression, the appropriate course of action is to provide individual treatment first; group treatment can then be used to make further progress on interpersonal and intrapsychic material. Group treatment can also be a relatively low-cost way to continue treatment for clients who require long-term work.

SOCIAL CONSIDERATIONS AND DIVERSITY Epidemiological studies in different countries have found large differences in prevalence of depression; presumably, these differences are at least partially due to differences in culture. At the times the surveys were done, depression ranged from a high of 19.0% in Lebanon to a low of 1.5% in Taiwan. The United States is intermediate, with different prevalences found in the NCS (Kessler, 1994), which surveyed participants from 1990 to 1992, and the Epidemiological Catchment Area study (Weissman, Bruce, Leaf, Florio & Holzer, 1991), which surveyed participants from 1980 to 1984. There were differences in methodology that may account for some of the differences in the findings. The NCS had a larger and more representative sample, used DSM-IV rather than DSM-IIJ-R criteria, and investigated more extensively for indications of depression than did the Epidemiological Catchment Area study. It could also be, however, that the prevalence of depression in the United States increased during the decade or so that separated the surveys. One finding that is fairly consistent is that Asian countries, such as China, japan, and Taiwan, have lower rates of depression than Western countries such as the United States, Canada, and Germany. Differences in social support may play a large role in these variances; Western culture, with its emphasis on individualism, may produce more isolation and loneliness than Eastern sociocentric cultures. In addition, Eastern cultures tend to make less of a distinction between mind and body than Western cultures; thus, what may emerge as depression in the West could be a somatic or somatization disorder in the East. Ethnographic approaches reveal a number of depression-like syndromes in other cultures that may have vastly different meanings than those attributed in the United States. For example, pena in highland Ecuador is associated with many symptoms of depression, such as "crying spells, poor concentration, anhedonia, social withdrawal, poor personal hygiene, sleep and 32

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

appetite disturbance, gastrointestinal complaints, and heart pain" (Tsai &. Chentsova-Dutton, 2002, p. 470). Personal loss is generally the precipitant of pena, as it often is with depression. However, according to Tousignant and Maldonaldo (cited in Tsai & Chentsova-Dutton, 2002), pena is an appeal for payment or social reciprocity, for the incurred loss. Unlike depression in the United States, which is viewed as individual psychopathology, pena is part of the social balance in highland Ecuador. Similarly, in New Guinea, the Kaluli people are highly emotionally expressive. Grief reactions, akin to what we might view as sadness or depression in the United States, are integrated into the culture through ceremonies, rituals, and "scripted" social interactions. These expressions then become part of the social negotiations within the culture, which help individuals to get their needs met. This appears to have a strong protective effect against depression in that culture (Scheflielin, cited in Tsai & Chentsova-Dutton, 2002, pp. 469-70). As Castillo (1997) observed, In a society with dominance hierarchies, individuals at the low end of the social scale have a stigma or impaired identity imposed upon them by dominant groups. The moral career of these stigmatized individuals is compromised in interpersonal relations. The term moral career refers simultaneously to the moral status and the morale of the individual. The moral status of individuals is an indication of their perceived value in society—that is, whether they are "good" or "bad" persons as judged by the cultural definitions of morality within the context of the social dominance hierarchy. . . . When moral status is compromised in this fashion, the individual's morale or sense of self-esteem can also be negatively affected. (Goffman, 1963, p. 42)

The consequences of stigmatization fit in well with Abramson et al.'s (1978) revised learned helplessness model. The consequences of being the "wrong" race, gender, ethnicity, social class, religion, or sexual orientation are often internalized by individuals as a feeling or belief that in fact there is something wrong with them. Because these demographic characteristics are immutable or difficult to change and impact a many areas of their lives, they see their predicament as stable and global (Castillo, 1998). Thus, individuals from stigmatized or disadvantaged groups are generally more prone to depression. There is a powerful argument that the traditional social roles of women, as described, for example, by J. H. Williams (1987) and Skeggs (1997), have a significant impact on depression. Because of women's traditionally subordinate role in our culture, they are more prone to anxiety, depression, and feelings of helplessness than men. Similarly, submissiveness and fear of abandonment are more consistent with women's social role than men's. Castillo (1998) noted that women in the United States are more likely than men to experience discrimination, harassment, and poverty. Nolen-Hoeksema, Larson, and Grayson (1999) studied a community sample of over 1,100 adults AN OVERVIEW OF DEPRESSION

33

longitudinally and affirmed that "chronic strain, low mastery, and rumination were each more common in women than in men and mediated the gender difference in depressive symptoms" (p. 1061). Further, her study demonstrated that this pattern led to a vicious circle, in that depressive symptoms led to increased rumination and decreased mastery over time. These notions are consistent with the findings of a study by Lynn Collins (1998), which linked social status to the development of psychological symptoms. Collins showed her classroom students (the research participants) a film of the Stanford prison experiment (Haney, Banks, & Zimbardo, 1973). Collins put together a list of symptoms of mental disorders and had participants rate how characteristic these symptoms were of men, women, "prisoners," and "guards." What she found, as demonstrated in the ratings, was that the prisoners exhibited symptoms of depression, anxiety, and helplessness— symptoms traditionally more prevalent in women. Conversely, the guards displayed aggression, arrogance, and other symptoms of antisocial and narcissistic disorders—diagnoses given predominantly to men. What was especially ingenious about this study was that because both the guards and the prisoners were male neither gender roles nor biological sex could explain the group differences. In addition, because of randomization, explanations based on personal variables (their upbringing, family dynamics, trauma history, etc.) were ruled out. The likeliest explanation for the differences in symptoms between the prisoners and the guards is that their assigned social roles influenced their identities and behaviors. This theory fits with data that show that the prevalence of depression is relatively high among, for example, gay teens and the poor (Herrell et al., 1999; Otis & Skinner, 1996; Simons et al., 2002; van Heeringen & Vincke, 2000). However, awareness of the difference in prevalence between men and women in most mental disorders is potentially confounded by differential rates of help-seeking behavior. Women are more likely to seek psychological help for most conditions, especially for depression and anxiety. For men in our culture, asking for help is seen as a sign of weakness or dependence; for women, asking for help bears no such stigma (Tannen, 1990). It is probable that some of the difference between diagnosis rates for men and women is due to women's greater comfort in going for help, especially with a mental health issue, though it is difficult to estimate the precise magnitude of that effect. In addition, differential rates have been found not only in clinical samples, but also in epidemiological studies (Nolen-Hoeksema, 2002); these differences are more difficult to explain on the basis of self-selection for treatment. On the other hand, a study of over 2,000 referred and 1,100 nonreferred adolescents found that among mental-health-referred, but not nonreferred, adolescents, rates of depression were higher in girls than in boys (Compas et al., 1997). The authors suggested that these gender differences were apparent in only a small subset of adolescents. Further research is needed to clarify the impact of gender and the reason for the impact. 34

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

People from other cultures may have vastly different experiences of distress that are shaped by their culture. Guilt, self-denigration, existential despair, and suicidal ideation have been found to be less prevalent or absent in non-Western cultures. Conversely, somatic symptoms are more pronounced in other societies. The World Health Organization Collaborative Study, which examined depression in five different countries (Canada, India, Iran, Japan, and Switzerland) found that feelings of guilt were more than twice as prevalent in the Swiss sample than in the Iranian one, and somatization was twice as high in the Iranian sample as in the Canadian one (see Sartorius et al., and Thornicroft & Sartorius, both cited in Castillo, 1998). Sociocultural upheaval can also lead to depressive symptoms. For example, the rate of completed suicides in Micronesia underwent an eightfold increase from 1960 to 1980, a period of rapid modernization accompanied by the breakdown of traditional religious and social organizations (Desjarlais, Eisenberg, Good, & Kleinman, 1995, cited in Castillo, 1997). A striking example of the difference in meaning of distress in different cultures was illustrated by Kabat-Zinn (1994): In our society, one might speak of an epidemic of low self-esteem. In conversations with the Dalai Lama during a meeting in Dharamsala in 1990, he did a double take when a Western psychologist spoke of low self-esteem. The phrase had to be translated several times for him into Tibetan, although his English is quite good. He just couldn't grasp the notion of low self-esteem, and when he finally understood what was being said, he was visibly saddened to hear that so many people in America carry deep feelings of self-loathing and inadequacy. Such feelings are virtually unheard of among the Tibetans. They have all the severe problems of refugees from oppression living in the Third World, but low self-esteem is not one of them. But who knows what will happen to future generations as they come into contact with what we ironically call the "developed world." Maybe we are overdeveloped outwardly and underdeveloped inwardly. Perhaps it is we who, for all our wealth, are living in poverty, (pp. 162-163)

In part, the Dalai Lama's perspective may reflect the difference between sociocentric and egocentric cultures. In the West, the concept of individualism permeates. We are encouraged to pursue our goals and maximize our potential; we believe in the concept of individual rights, including the right to pursue happiness. If one is not pursuing happiness, then, in Western culture, one is behaving pathologically. In sociocentric cultures, the well-being of the group is considered paramount, with individual needs being secondary. Within such a context, low self-esteem is far less comprehensible because the emphasis is not on the self in the first place. Sadness occurs, of course, but it is more likely to be a shared experience rather than a personal failing. AN OVERVIEW OF DEPRESSION

35

STRENGTHS OF PATIENTS WITH DEPRESSION In my experience, individuals with depression tend to have a variety of positive qualities. Many are introspective and in touch with their feelings. I have found them by and large to be responsible—willing to take ownership of their own feelings and their impact on others. To the extent that they go overboard in that regard, it is generally easier to help depressed individuals reduce their guilt and bring their oppressive superegos into balance than it is, for example, to help poorly socialized individuals restrain their ids and develop a sense of social responsibility and guilt. Individuals with depression are generally eager to get well, which serves as a great motivation in therapy. Some studies found that depressed individuals are more realistic in their predictions than nondepressed ones, who were excessively optimistic (for a review of this research, see, e.g., Dunning & Story, 1991). This counterintuitive finding spawned a generation of research, which has generally indicated that depressed individuals are more realistic under contrived laboratory conditions but not in more realistic circumstances (Dunning & Story, 1991; Pacini, Muir, &. Epstein, 1998). Although these theories are subject to ongoing research, tentative initial conclusions suggest that depressed individuals (more than nondepressed participants) make overly optimistic estimates at the beginning of such studies, when they are under relatively little stress. Then, impairments associated with depression interfere with goal completion. Cognitive distortions similar to those noted by A. T. Beck et al. (1979), such as beliefs that one is incompetent, play an important role. Helplessness beliefs (Seligman, 1975) impair efficacy and thus render optimistic predictions inaccurate. Vicious circles (Millon, 1996), in which individuals with depression underestimate the effort required to complete a task and then initially fail, leading to further giving up, also play a role, and, similarly, positive efforts made by nondepressed individuals that are then rewarded lead to goal attainment. At this time, the depressive realism phenomenon should be considered primarily a laboratory occurrence of limited clinical utility.

THE RELATIONSHIP BETWEEN PERSONALITY DISORDERS AND DEPRESSION Seven models are most frequently cited as underlying the relationship between PDs and depression (Dolan-Sewell, Krueger, & Shea, 2001). With the exception of the independence model (which, if true at all, is not relevant to the material addressed in this volume) and perhaps the "scar" model (which does not appear to have elicited PD or depression-related studies at this time), all of the other models are implicit in conceptualizations that appear throughout this book. Each model is considered below, with some 36

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

examples of how the model relates to specific depression-PD interactions that are addressed later on. Independence Model The independence model indicates that there is no relationship between Axis I and Axis II conditions. If the rate of comorbidity does not exceed the rate of chance occurrence predicted by the base rate of the disorders, that would count as supportive evidence for the independence model. For example, if a PD occurred in 10% of the population and major depression in 20% and if the comorbidity of the two disorders was 2%, that would support the independence model. In certain areas, limited support is available for the independence model. For example, a study by Petersen et al. (2002) showed that treatment-resistant depression was not related to the presence of a PD. However, for the most part, the comorbidities between depression and PDs exceed chance levels. Shea, Widiger, and Klein (1992), in their review of the literature, noted that high rates of comorbidity for PDs and depression are the norm. Citing nine studies, Shea et al. noted that in samples of depressed participants, 23% to 87% of the participants have had PDs; in most of these nine studies, the PD rate is 30% to 40%. Similarly, in the six available studies of the rates of depression in samples of individuals with PDs, the range was approximately 24% to 87%. These rates clearly exceed the amount of overlap one would anticipate on the basis of the prevalence of each disorder taken separately. Common Cause Model The common cause model applies if there is a shared element between the two disorders that causes both. The cause can be biological, psychological, environmental, or sociological. For example, a chemical imbalance in the serotonin system may underlie both depression and impulsive behavior (e.g., as seen in borderline PD; see Soloff, Kelly, Strotmeyer, Malone, & Mann, 2003; Soloff, Meltzer, Greer, Constantine, 6k Kelly, 2000). Thus, an individual with either disorder would be at risk for the other. Thus SSRIs, which are antidepressants, are useful in treating borderline PD (Rinne, van den Brink, & Luuk van Dyck, 2002). Similarly, sexual abuse may be a risk factor for both borderline PD and depression (Rose, Abramson, Hodulik, Halberstadt, & Leff, 1994; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989). Techniques that facilitate healing the emotional trauma of sexual abuse would, according to this model, reduce symptoms of both disorders. Spectrum and Subclinical Model Like the common cause model, the spectrum model views one disorder as a milder version of the other disorder; in this case, the Axis II disorder AN OVERVIEW OF DEPRESSION

37

would be a milder version of the Axis I disorder. There is good evidence that schizotypal PD and schizophrenia have a "spectrum" relationship, and although the evidence is not quite as strong, it appears that paranoid and schizoid PDs are part of the same spectrum (Siever, 1992). Regarding a relationship between depression and PDs, depressive PD—which is not discussed elsewhere in this volume because it is covered in the appendix of DSM-IVTR—is probably related in a spectrum fashion to major depression and dysthymic disorder. There are theories that borderline PD lies on a spectrum with bipolar disorder, based on shared features such as affective instability. Although proof of this connection is lacking, the theory led to experiments with anticonvulsants and lithium to treat borderline PD; however, this approach has had mixed success (see the section on medications in chap. 7, this volume). Predisposition—Vulnerability Model There is a possibility that having one disorder will predispose an individual to getting another disorder. In this regard, PDs, which are seen as developmentally based and having broad implications regarding the person's functioning, would be more likely to form the context into which the depression would fit. However, it is also possible that childhood depression would predispose an individual to develop a PD. A study by Daley, Hammen, Davila, and Burge (1998) is illustrative of this point. It demonstrated that the presence of a Cluster A or B PD predicted later depression in a sample of late adolescent women. The causal path consistent with Daley et al.'s analysis was that individuals with Cluster A and B PDs generated larger numbers of stressful life events, which in turn increased the likelihood of depression. The vulnerability model fit better than the pathoplasticity model (discussed below); PD did not increase the risk of depression in response to stress. Complications-Scar Model Like the vulnerability model, the complications model presumes a sequential relationship between two disorders. In this theoretical configuration, a second disorder develops in the context of the first. The first disorder remits, but the other disorder continues on, exacerbated by the effects of the original comorbid disorder; it is as if the remitted disorder left a "scar" that complicates the recovery from the lingering disorder. An example would be an individual with borderline PD who then develops depression and, after intensive treatment, no longer meets the criteria for borderline PD but is still more vulnerable to depression as a consequence of having had borderline PD. In such an instance, residual borderline PD symptoms may be the causal factor that increases the vulnerability to depression. I am not aware of any 38

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

studies that support the validity of this model in specific PD-depression pairings, though it remains a theoretical possibility. Pathoplasty-Exacerbation Model In this model, the principal hypothesis is that the presence of one disorder will influence the course of another. The effects can be additive (pathoplasty) or synergistic (exacerbation). For example, depression likely increases the tendency of individuals with avoidant, schizoid, and schizotypal PDs to socially withdraw, which can then further exacerbate both conditions. A number of studies support the notion that PDs interact with depression. For example, llardi, Craighead, and Evans (1997) found that the length of remission of unipolar depression was over 7 times longer among clients who did not have PDs compared with those who did. In another study, an interaction of personality style and life events predicted depression. Specifically, the researchers predicted and found that self-critical patients were at high risk for depression relapse if they experienced adverse achievementrelated events, and dependent individuals were vulnerable to depression if they experienced negative interpersonal life events (Z. V. Segal, Shaw, Vella, & Katz, 1992). A study of the impact of PDs on cognitive therapy outcome showed that outcomes were independent of PD status but that specific paranoid and avoidant beliefs predicted poorer outcomes (Kuyken, Kurzer, DeRubeis, Beck, & Brown, 2001). Psychobiological Models In the psychobiological model, shared biological mechanisms underlie depression and PDs (though presumably different PDs will have different associations with depression). Evidence of the validity of this model is growing. For example, a recent study of 720 child and adolescent twins showed that 45% of the covariation in depression and antisocial PD were attributable to common genetic factors (O'Connor, McGuire, Reiss, Hetherington, & Plomin, 1998). Such psychobiological models are a variant of the "common cause" model discussed above, and thus the biological example given in that section applies here as well (i.e., serotonin problems in individuals with depression and impulsive PDs).

CONCLUSIONS Perhaps what is most important to consider is that these models are not mutually exclusive, and they often overlap. We do not know for certain what the relationship is between PDs and depression, but it is likely complex. StayAN OVERVIEW OF DEPRESSION

39

ing with the PGT principle that integration occurs at the level of the person rather than at the level of theory, we can safely conclude that most or all of these models refer to at least some of the people, some of the time. Throughout the remainder of the book, reference will be made to these models when they fit the available data.

40

PERSONAL/TY-G VIDEO THERAPY FOR DEPRESSION

3 DEPRESSION INPARANOID PERSONALITY DISORDER

The phenomenology of paranoid personality disorder (PD) is powerfully portrayed in the poem "Paranoid," written by Lisa Ochenduszko (2003) and published on the Internet. The poem is reprinted only in part, but each stanza is complete and the ellipses are in the original. In the deepest recesses and corridors of my mind, You play there . . . You run freely, gaily In my mind you make the fantasies, hollowed out screams, fearful cries . . . Denied In my mind where you hunt your prey, Your hunger ravished, eating me. . . . Destroyed In my mind or what is left of my mind, you reign as supreme. Ideal dictatorship. . .. Paranoid. . . .

41

This gifted writer has portrayed the pain, emptiness, and fear that dominate the life of the person with paranoia. The frightening image of being destroyed, as if devoured from the inside, represents the internalization of the sadism to which the person was presumably subjected. The poet portrays a person who sees evil in others and has difficulty setting a boundary to keep it out ("In the deepest recesses and corridors of my mind, / You play there ... / You run freely"; "In my mind you make the fantasies").1 Although real abuse presumably occurred, in theory, there are also instances in which it is the person portrayed by the poet who feels anger or hate and then projects it onto an otherwise innocent person; this projection occurs outside of conscious awareness. Glimpses of projection appear several times in the poem. Is the feared individual able to truly "run freely" in the person's mind and to create fantasies? Or do the fantasies come, at least in part, from within? The fear of being controlled by another and the exhaustion from the defensive efforts, both so movingly portrayed, capture the essence of paranoid PD. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, 2000a), "Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent" (p. 685). Guarded and either hostile, fearful, or both, they are among the most difficult groups to treat with psychotherapy. Their very modus operandi—trust no one—is so contrary to one of the necessary conditions of psychotherapeutic treatment that treatment often grinds to a halt after just a few sessions. There is more hope that the individual with both paranoid PD and depression will stay in treatment because the depression is distressing and increases the client's motivation to persist in treatment. It is important to distinguish paranoid PD from paranoid (delusional) disorder and from paranoid schizophrenia. Sometimes they co-occur, as in the case example at the end of this chapter, but not always. In general, I have found that people with paranoid schizophrenia and delusional disorder (but without paranoid PD) are remarkably trusting. As I have listened to elaborate tales of Federal Bureau of Investigation, Mafia, and Central Intelligence Agency conspiracies that ensnared the beleaguered client, I have often waited for the other shoe to drop—to hear the dreaded, "How do I know that you're not part of the conspiracy?"—but it never happened. Often I have found individuals with paranoid schizophrenia to be too trusting, because their psychosis often interfered with logical thinking that would have helped them to set appropriate boundaries. Nor did people with delusional disorder ever consider me part of the conspiracy. Such is not the case with individuals with paranoid PD. By definition, it is extremely difficult to establish trust. 'The poet has said in a personal communication that she was writing not about herself but about a loved one.

42

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

EPIDEMIOLOGY In Pepper et al.'s (1995) dysthymic disorder sample, 11% had paranoid PD. In another sample of depressed clients, approximately 22% had paranoid PD (Fava et al, 1995). In a sample of 249 depressed outpatients, 5% were diagnosed with "definite" and 18% with "probable" paranoid PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). In a sample of 352 clients with both anxiety and depression, approximately 17% had paranoid PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Zimmerman and Coryell (1989) studied a community sample of 797 individuals that included 143 individuals who were diagnosed with PDs. Among individuals with major depression, 1.7% met the criteria for paranoid PD. Thus the range is approximately 2% to 22%. Likely reasons for the wide range include natural sample variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria—-for example, some studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), and others used criteria from the revised third edition (DSM-III-R; American Psychiatric Association, 1987). In regard to the converse question, among those with paranoid PD, 28.6% met the criteria for major depression (Zimmerman & Coryell, 1989). WHY DO PEOPLE WITH PARANOID PERSONALITY DISORDER GET DEPRESSED? Individuals with paranoid PD have thought patterns that generate both anxiety and depression. The fear that others cannot be trusted and that others are actively undermining one's efforts leads to anxious hypervigilance. Under such circumstances, many get worn out and sink into feelings of hopelessness and pervasive cynicism. Additional failures related to depression symptoms (such as slowed mental processing, motivational difficulties, etc.) are further attributed to external forces, such as others' malevolence. "I would be fine if not for so-and-so's interference" is a common theme. This conceptualization is consistent with the predisposition-vulnerability model, in that the paranoid PD places the person at risk for depression. It also suggests the exacerbation model because the depression and paranoia intensify one another (see chap. 2). HOW A PERSON BECOMES AND REMAINS PARANOID: THEORIES OF PARANOID PERSONALITY DISORDER AND THEIR ASSOCIATED TREATMENTS For individuals with comorbid depression and paranoid PD, it is hard to imagine a satisfactory resolution of Axis I symptoms without a concurrent PARANOID PERSONALITY DISORDER

43

reduction of pathology on Axis II. The depression is likely to be tinged with anger, and difficulties with trusting a health care professional would strongly interfere with therapeutic progress in any modality. Thus, to treat the depression, trust must be established—that is, the paranoid personality pathology must recede, at least to some degree. Major theories of understanding and treating paranoid PD are presented below, with an emphasis on the individual with comorbid depression where feasible. Biological Factors Paranoid PD is part of the schizophrenia spectrum (Siever, 1992). For example, a study found that paranoid PD was twice as likely to occur in schizophrenic probands than in nonpatient controls (Baron, Gruen, &Ranier, cited in Nigg & Goldsmith, 1994). Paranoid PD appears to be intermediate between schizotypal and schizoid PDs in its genetic association to schizophrenia (for a review, see Nigg & Goldsmith, 1994). DiLalla, Carey, Gottesman, and Bouchard (1996) found that the Minnesota Multiphasic Personality Inventory Paranoia scale had a heritability estimate of 28%. Livesley, Jang, and Vernon (1998) found that suspiciousness scores had a heritability of 32.5%. In their study of the heritability of personality disorders in children and adolescents, Coolidge, Thede, and Jang (2001) found that the heritability estimate for paranoid PD was 50%. As with other personality disorders, then, paranoid PD appears to be moderately heritable. To my knowledge, there are no substantiated theories on the neurobiology of paranoid PD per se. As part of the schizophrenia spectrum (Siever, 1992), and to the extent that it is related to paranoid schizophrenia, paranoid PD involves the functioning of the dopaminergic systems. In Cloninger's theory (Cloninger, 1987), paranoid PD would presumably represent the high extreme of the "harm avoidance" dimension. Cloninger (1998) has shown that high harm avoidance is related to specific activities in the brain, such as higher levels of activity in the right amygdala (a part of the limbic system, important in processing emotions) as well as the right orbitofrontal cortex and the left medial prefrontal cortex (parts of the frontal lobes that are involved in executive functions such as planning). I know of only one empirical evaluation of medications for paranoid PD, the Ekselius and von Knorring (1998) study discussed in chapter 1. The selective serotonin reuptake inhibitors sertraline and citalopram appeared to be helpful in decreasing paranoid PD symptoms among the 84 individuals in their sample with paranoid PD. The remission rate for paranoid PD after 24 weeks of treatment was 43% for the sertraline group and 30% for the citalopram group. The sertraline group had a mean decrease of .5 criterion pre- to posttreatment; the corresponding figure for the citalopram group was .7 criterion. Unfortunately, because there was no medication-free compari44

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

son group, the results of the study are inconclusive; however, given the generally persistent nature of personality disorders, the finding is noteworthy and warrants further investigation. In the absence of additional studies, it is worthwhile to consider the clinical observations provided by Joseph (1997). He divided paranoid PD into symptom clusters that are amenable to intervention with medications. Paranoia and ideas of reference can be treated with antipsychotics, such as risperidone or olanzapine (which he preferred), or other drugs, such as haloperidol, fluphenazine, or chlorpromazine. He noted that dosages are "approximately one-tenth to one-fourth of what is used for treating florid paranoia and psychoses" (p. 27). In his experience, such medications are quite effective in reducing paranoid ideation in people with paranoid PD. Joseph argued that symptoms such as such as rigid thinking and preoccupations with others' loyalty can be considered obsessional features and treated with selective serotonin reuptake inhibitors such as fluoxetine, sertraline, orparoxetine. Vigilance, guardedness, and tension may respond to anti-anxiety agents such as lorazepam, alpraxolam, and clonazepam. Anger, excessive emotional sensitivity, and irritability are a cluster of symptoms that can be treated effectively with serotonergic antidepressants or tricyclic antidepressants, with bupropion also being somewhat effective. Constricted affect, social withdrawal, and social anxiety can be conceptualized as being similar to negative symptoms of schizophrenia; Joseph noted, "They are likely to respond to low doses of risperidone or olanzapine, and, paradoxically, to serotonergic antidepressants and bupropion" (p. 30). In most cases, then, his treatment consists of long-term use of a low-dose antipsychotic and a serotonergic antidepressant, with short-term administration of a benzodiazapine. Although reasonable, Joseph's theoretical assumptions, as well as his assertions of the efficacy of particular medications for use with this population, require empirical verification. Randomized clinical trials with any medication proposed for this population are essential. Psychological Factors In the biopsychosocial model, the psychological level refers to the individual and his or her intrapsychic and interpersonal world. Important areas to consider include the person's learning history, thoughts, feelings, unconscious motivations, and relationships. Various schools of thought emphasize different aspects of the person's functioning and will be described in turn below. Millon's Theory According to Millon (1969/1985, 1981, 1996), paranoid PD is a severe "dysfunctional variant," rather than a basic personality type in its own right. Paranoid PD occurs when a personality disorder deteriorates. The basic patPARANOID PERSONALITY DISORDER

45

terns that typically underlie paranoid PD (and Millon's labels for the subtypes) are narcissistic (which becomes the fanatic paranoid), sadistic (malignant), obsessive—compulsive (obdurate), avoidant (insular), and passive— aggressive-negativistic (querulous). In Millon's theory there is no developmental background that is specific to the disorder; it depends on the subtype. It is a "common endpoint" theory, in which many developmental beginnings, shaped by experience, lead to the hypervigilant mistrust seen in paranoid PD. The seeds of paranoid PD find fertile soil in narcissistic psychopathology. There is an inevitable set of beliefs that undergirds the paranoid thinking seen in this disorder: In order for someone to be undermining me, I must be important; in order for them to feel threatened by me, I must be very powerful; in order for them to feel jealous of me, I must be very special.

The arrogance that lurks just beneath the surface presentation often drives and fuels the paranoid thinking; the gratification derived from the grandiosity props up and maintains the defense, and the externalization and blame protect the person from self-reproach and further reinforce the pattern. What turns narcissism to paranoia is cold, harsh reality that fails to gratify even a modicum of the need for validation. A person with paranoid PD's perception of his or her talents and abilities are miles apart from the perceptions of others. If such individuals could simply accept their limitations and focus on activities they do adequately well, all would be copacetic; however, such is not the case. Narcissistically driven, they continue to push, feeling the constant sting of rejection. Filled with blame and condemnation, their accusations and conjectures drift further and further from reality into a quasidelusional or fully delusional form. People with avoidant origins are among those who are more constitutionally prone to paranoia. Typically shy and hypersensitive from the beginning, they consistently perceive rejection from an early age. Like their less pathological avoidant counterparts, insular paranoids were subject to harsh parental deprecation. Unlike the avoidant, however, the future paranoids found no safe quarter; withdrawal was insufficient, and persecution seemed to follow them. They lacked natural sophistication and cleverness as defenses, and thus every sling and arrow hit its mark; eventually, they came to view everyone as a potential torturer. The querulous paranoid has an originating background similar to the passive-aggressive-negativistic pattern. Millon (1996) noted that the querulous paranoid is a variant related in part to a basic negativistic pattern. These paranoids often evidence irregular infantile patterns and an uneven course of maturation, traits that often promote inconsistent and contradictory parental management. Their characteristic irritable

46

PERSONALITY-G (JIDED THERAPY FOR DEPRESSION

affectivity may be attributed to low neurophysiological thresholds of responsivity. (p. 719) As is the case for others with basic personality patterns who deteriorate to a paranoid level of functioning, increasing mistrust is precipitated by agonizing disappointments and rejections. Fundamentally ambivalent on the selfother dimension, querulous paranoids are pushed to rely increasingly on themselves, and their resentments of others grow ever deeper. Ultimately, they become "sullen, resentful, obstructive, and peevish, openly registering feelings of jealousy, of being misunderstood, and of being cheated" (Millon, 1996, p. 720). Like individuals with sadistic PD, malignant paranoids have backgrounds of parental harassment and animosity. They acquire hostile behaviors, which are reinforced by peers (who give in to them) and parents (who inadvertently reward hostility with attention or purposefully cultivate an aggressive approach to life). Poverty may encourage a "survival of the toughest" adaptation. Millon (1996) noted, Anticipating resentment and betrayal from others, future malignant paranoids moved through life with a chip-on-the-shoulder attitude, bristling with anger and reacting before hostility and duplicity actually occurred. Resentment and antagonism were projected. Dreading being attacked, humiliated, or powerless, they learned to attack first, (pp. 717-718) As with other paranoids, harsh reality, rejection, and humiliation push them to engage in increasingly extreme defensive maneuvers. They become more angry, hostile, and hypersensitive, seeing others as more and more treacherous. Eventually, they trust almost no one and often take on delusional, persecutory beliefs. Regardless of its origin, a variety of vicious circles maintain the paranoid pattern. Perhaps most powerfully, suspicious mistrust breeds suspicious mistrust. The guarded presentation of individuals with paranoid PD elicits the belief that they are hiding something. Failure to reciprocate small trusting gestures, such as self-disclosure, by others short-circuits the rapportbuilding and trust-enabling process. Their proclivity to discharge hostility in brief bursts leads to numerous interpersonal difficulties. As noted by Millon (1996), Trapped in a timeless web of deceit and malice, their fears and angers may mount to monumental proportions. With defenses down, controls dissolved, and fantasies of doom running rampant, their dread and fury increase. A flood of frantic and hostile energies may erupt, letting loose a violent discharge, an uncontrollable torrent of vituperation and aggression, (p. 721) Obviously, the targets of such aggression typically become more actively opposed to and angry with the person with paranoid PD who attacked them.

PARANOID PERSONALITY DISORDER

47

Finally, the delusional or quasi-delusional reconstruction of reality by persons with paranoid PD further worsens their social situation. Their suspicions often cross the line into actual accusations or, in more extreme cases, physical assault. This pattern elicits the feared animosity and vengeance that generally were not there prior to their own attacks on others. I recall an extremely paranoid client whom I knew (but never treated) when I was working at a Veterans Administration hospital who seemed to have all of these perpetuating factors. He never made any friends or even strong acquaintances on the unit. To my knowledge, he never opened up or shared any personal information with anyone. I learned from staff that in his job as a subcontractor for a private detective, he was to sit and watch people, all day long, to see if they engaged in unseemly or illegal activities. This client also had antisocial PD and, for example, would rent furniture and never pay a dime until the company came to repossess it; it is my understanding that he was also involved in the illicit drug business. He met his end by being shot to death. I do not know the circumstances, but I would suspect that his antisocial and paranoid behaviors played an important role. Regardless of the particular subtype, depression in the person with paranoid PD often reflects a sense of exhaustion—battle fatigue from a war that will not end, a surrender to the implacable foe. Once it begins, the depression itself leads to further exhaustion and hopelessness. Although this feeling of depletion is painful, it also signals the need for change and provides the impetus for growth. Cognitive-Behavioral Conceptualization and Interventions The superficial manifestations of paranoid PD are obvious— hypervigilence, suspiciousness, and mistrust. However, cognitive theory connects these surface behaviors and beliefs to a more treatable underlying selfesteem deficit: The paranoid individual's intense vigilance and defensiveness is a product of the belief that this is necessary to preserve his or her safety. If it is possible to increase the client's sense of self-efficacy regarding problem situations so that he or she is reasonably confident of being able to handle problems as they arise, then the intense vigilance and defensiveness seem less necessary. This should result in some decrease in vigilance and defensiveness that could substantially reduce the intensity of the client's symptomatology, making it much easier to address his or her cognitions through conventional cognitive therapy techniques, and making it possible to persuade him or her to try alternative ways of handling interpersonal conflicts. Therefore, the primary strategy in the cognitive treatment of [paranoid PD] is to increase the client's sense of self-efficacy before attempting to modify other aspects of the client's automatic thoughts, interpersonal behavior, and basic assumptions. (A. T. Beck, Freeman, & Davis, 2004, p. 125) 48

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

For depressed clients with paranoid PD, there would typically be even greater sensitivity to threats to self-esteem. Feelings of fatigue and hopelessness can make it feel as if their usual defensive efforts are too draining, thereby tempting them to withdraw. For the client in therapy, such attempts at withdrawal have been unsuccessful, and the person may feel damaged and vulnerable. It is often easier, more efficacious, and more comfortable, then, for the client to build skills than to decrease problematic behaviors directly. Often, competing behaviors (differential reinforcement of other behaviors) can "squeeze out" the ineffective behaviors without the need for the client to use behavioral inhibition. "Don't be so suspicious," whether the message is explicit or implicit, is an ineffective approach because it requires behavioral inhibition and it does not provoke a behavior for which to provide positive reinforcement. Instead, increasing skills such as assertiveness and interpersonal communication will naturally provide contrary evidence to the client's suspicions. It is also important to work with the client on his or her cognitive interpretations, because individuals with paranoid PD routinely twist data to fit their preconceptions. Helping individuals learn Socratic dialogue, by which they she can question the evidence themselves, is an important step. It is not, however, the first step. Of all the personality disorders, and, most likely, of all the disorders in the entire DSM-IV-TR—with the possible exception of autistic disorders and reactive attachment disorder—paranoid PD presents the largest and most persistent barricade to forming a therapeutic alliance. By definition, there are profound difficulties trusting others that must become part of the therapeutic process. It is not being overly pessimistic to say that in many cases this barrier is insurmountable. Nonetheless, there are strategies to improve one's odds of success. Beck and his associates (A. T. Beck et al., 2004; A. T. Beck & Freeman, 1990) have suggested that the therapist accept the client's mistrust and ask the client to allow the therapist to build trust through actions. Most clients with paranoid PD will find that this approach will fit with their worldview, because they tend to persistently scan others' actions to determine if they are trustworthy. In addition, it is wise to start with behavioral techniques, because cognitive techniques require too much trust and self-disclosure; once a solid therapeutic alliance is formed, cognitive techniques can be introduced. Above all, within the cognitive-behavioral therapy model, it is essential to maintain a collaborative stance. Regularly checking in with clients and making sure they understand and agree with the treatment plan is a strong safeguard against potential therapy-ending misunderstandings. Finally, giving clients increased control (e.g., more homework and less frequent sessions) can help them to preserve their autonomy, which is often a prerequisite to continuing treatment. The basic cognitive-behavioral therapy relationship, which is problemfocused and less intimate than many other forms of treatment, is generally a PARANOID PERSONALITY DISORDER

49

good fit for the client with paranoid PD. However, without special attention to the relationship hurdles of paranoid PD, the therapy is likely to fail. Beck and his associates (A. T. Beck et al, 2004; A. T. Beck & Freeman, 1990) have paid attention to such issues from a cognitive perspective, as alluded to above; however, the cognitively oriented therapist would be wise to peruse writings from other theoretical perspectives as well. Gabbard (1994) provided a balanced, practical, and insightful review of countertransference phenomena, written in language that is accessible to the nonpsychodynamically oriented practitioner (see the sections in this chapter on psychodynamic therapy and countertransference). Cognitive techniques can also address the quasi-delusional suspiciousness associated with paranoid PD. For approximately the past 10 to 15 years, an extremely exciting literature has been developing in the treatment of psychotic disorders using cognitive therapy. A number of research studies have demonstrated substantial reductions in delusional beliefs. This area is just now beginning to mature, with literature reviews, overviews, and books emerging to connect formerly scattered and isolated reports (Gould, Mueser, & Bolton, 2001; Haddock et al., 1998; Kingdon & Turkington, 1994). For many years, the prevailing wisdom in the field has been, "You can't talk someone out of his delusions," a saying that I still believe is largely true. However, you can train someone to talk himself out of his delusions. The primary technique, as alluded to above, is the application of Socratic dialogue. "What is the evidence for your belief?" as in all Socratic dialogue, is a basic question, but it does not go quite far enough (the delusional paranoid always has a plethora of such evidence on hand). An important extension is "What would count as evidence that your belief is incorrect?" Of course, a strong relationship must exist before such a question can even be raised. However, introducing the possibility of disconfirmation removes the delusion from the realm of tautology and places it within the empirical world. In addition to empirical disconfirmation strategies through Socratic dialogue, thought records can be introduced to work on the motivational schemas that support the beliefs. For example, the person with paranoid PD likely holds the belief, "By scanning the environment, I help myself to feel safe." Using thought records, one may determine that the more such individuals scan the environment, and the more they ruminate about safety, the less safe they feel. When the empirical and emotional pillars supporting the delusion are sufficiently weakened, the delusion itself often collapses. We lack empirical data to know for sure, but theory would indicate that the client's depression is tied to the exhausting excessive vigilance and grinding social isolation. Finding some safety within the therapeutic relationship, and ultimately beyond, is likely to provide feelings of relief as well as an antidepressant effect. Relief from depression would then enhance social functioning, promoting a positive spiral of affective and personality functioning. 50

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Client-Centered, Humanistic, and Existential Therapies Patience, validation, and unconditional positive regard are a prerequisite for developing a relationship with someone who has paranoid PD. It is worth noting, however, that the ordinary level of warmth conveyed by a client-centered therapist is likely to be seen as threatening and a form of deceitfulness, so a more businesslike approach is probably more effective at first. Ultimately, however, over an extended period of treatment, a warm relationship could be extremely healing to the depressed person with paranoid pathology. Psychodynamic Therapy According to Melanie Klein (1946/1996), paranoia is part of the normal process of development. She described the "paranoid-schizoid position" as an early developmental stage. Splitting is the primary defense mechanism used. Terrified that warm and loving feelings will be overwhelmed by hateful and aggressive feelings, infants split off and project their emotions. Too young and immature to experience the mother as a whole person, they concretely experience the mother's breast as their principal attachment. When milk flows out, they experience the "good breast," which symbolizes love and nurturance; when the breast is dry or does not gratify them, they experience it as the "bad breast," which is evil and frustrating. Stuck in this position, persons with paranoia split off and project their hostile feelings onto others, who are then seen as persecuting them. This analysis implies that the person with paranoia will reexperience the anxiety that was relieved by the projection if forced to reintegrate the projected affect; it is consistently noted clinically that individuals with paranoid PD are loathe to acknowledge their own aggressive feelings toward others. It also suggests that an important part of the phenomenon of paranoid PD is excessive early frustration relative to warm nurturance and gratification. A further implication of the paranoid-schizoid position is that the individual tends to have fleeting and unstable object relations. Months of establishing trust can be undone in an instant if the therapist (or any individual) commits a perceived injustice; the client is likely to see this as "proof that the therapist had malicious intent all along. In addition, the individual is unable to maintain a detached, observing stance. The thought that someone is trying to undermine him or her is its own proof; there is no hypothetical "as if" (e.g., "It is as if he is trying to undermine me"). Instead, slights are viewed as real and malicious rather than perceived. Perhaps the most damaging barrier against establishing relationships for the person with paranoid PD is projective identification. Projective identification has three components: (a) projection of an unacceptable impulse onto another while continuing to experience the impulse (in the paranoid patient, the projected impulse is usually aggressive); (b) viewing the individual PARANOID PERSONALITY DISORDER

51

onto whom the impulse is projected as controlled by the projected impulse, and thus frightening; and (c) attempts to control the person, often in a way that provokes the feared behavior. A hypothetical example of projective identification and its capacity to undermine relationships was given by Gabbard (1994): Patient: Therapist: Patient:

I'm really angry with you because I've been sitting in the waiting room for half an hour. You told me to be here at 9:30 today. No, that's not true. I said 10 A. M. You said 9:30.

Therapist:

(a little louder and more forcefully) I said 10 o'clock. I wrote it down in my book.

Patient:

You're trying to trick me! You won't admit that you're wrong, so you try to make me think that I'm the one who's wrong.

Therapist:

(louder still) If I were wrong, I would admit it. On the contrary, I think you are the one who won't admit to being wrong, and you attribute that to me.

Patient:

I'm not going to take this harassment. I'll find another therapist! (pp. 424-425)

Projective identification involves the need to control others. But why this need? Deep down, people with paranoid PD have terrible self-esteem, believing that they are weak and ineffectual. Just as a weaker army uses a preemptive strike to capitalize on the element of surprise and maximize its effectiveness, people with paranoia believe that they are always in danger of being overwhelmed and destroyed by a superior force. Their grandiosity, then, is defensive and compensatory in nature; rather than reflecting a high selfopinion, it is a manifestation of precisely the opposite. To counter the destructive force of the projective identification, the therapist must, paradoxically, be totally open to it and accepting of it, allowing himself or herself to become a container for the negative affect. Gabbard (1994) gave an example of a better way to handle the prior situation: Patient:

I'm really angry with you because I've been sitting in the waiting room for half an hour. You told me to be here at 9:30 today.

Therapist:

Let me see if I understand you correctly. Your understanding was that you were to see me today at 9:30 instead of 10 o'clock?

Patient: Therapist:

Patient: 52

You said 9:30. I can certainly see why you might be angry at me then. Having to wait for someone for 30 minutes would make most people angry. You admit that you told me to come at 9:30?

PERSONAL/TY-G VIDEO THERAPY FOR DEPRESS/ON

Therapist:

Frankly, I don't remember saying that, but I'd like to hear more about: your recall of that conversation so I can find out what I said to give you that impression, (p. 426)

Thus, handling the client involves a persistently nondefensive, empathic, and supportive stance. Note, too, the businesslike and matter-of-fact approach taken by Gabbard above. Excessive warmth, as mentioned previously, is likely to breed suspicion and mistrust. Group Therapy Individuals with paranoid PD are not good candidates for processoriented group therapy at first. Their proclivity to elicit hostility and rejection from others is generally too strong, and they are likely to be scapegoated or otherwise rejected by the group. Rather, some progress should first be made in individual therapy; once the client is a bit more comfortable and trusting, then group approaches can be used. A psychoeducationally based skills group, however, could be considered earlier in treatment.

COUNTERTRANSFERENCE Theory and clinical observations suggest that countertransference is often a major obstacle to treatment of people with paranoid PD. Gabbard (1994) noted that "exasperation and impatience" (p. 426) often result from the relentless scrutiny by such clients. Therapists are also often tempted to burst the clients' bubble of grandiosity. Of course, to do so would typically rupture the therapeutic alliance as well. As indicated previously, projective identification requires special handling to avoid premature termination. The person with depression and paranoid PD presents the additional problem of feelings of hopelessness that can be induced in the clinician. If the therapist begins to feel hopeless, he or she must find rays of light in the darkness of the client's predicament; if this is not possible, then supervision or peer consultation is imperative. Throughout treatment, the wisest course of action is continued empathy and validation. Gabbard's (1994) illustration of how to handle projective identification, reviewed in the earlier section on psychodynamic therapy, provides an excellent illustration of how to remain empathic under trying circumstances. What little empirical research is available is consistent with clinical wisdom in the field. Graduate students who viewed a film of a therapy session with an individual simulating paranoid PD (without depression) indicated that they felt frustrated, guarded, perplexed, and fearful. The client's lack of trust, distant and suspicious demeanor, and failure to comply with an apparently reasonable request pulled forth the frustrated and confused feelings, while the client's thinly veiled hostility elicited fear and defensiveness (Bockian, 2002a). PARANOID PERSONALITY DISORDER

53

In treating persons with paranoid PD, I have found it helpful to remind myself that their guarded style is usually well grounded in their experience. Many people with paranoid PD have been severely betrayed and/or sadistically abused. As the old joke goes, just because you're paranoid does not mean that they're not all out to get you.

SOCIAL CONSIDERATIONS AND DIVERSITY Individuals with certain disabilities, especially deafness, may have symptoms that would indicate paranoid PD in a hearing person. For the young child who has never had hearing but is raised in a hearing environment, watching others communicate in a manner that is inherently foreign often leads to feeling isolated and alienated. In addition, lacking many ordinary social cues, such children often believe that others are talking about them. In reality, in a culture in which difference is not well tolerated, the other children probably are often talking about them, and perhaps making fun of them, thus lending credence to suspicious feelings. The disparity between minority and majority culture was brought to the forefront during the O. J. Simpson murder trial ("Behind the Verdict," 1995). Simpson, an African American, was accused of murdering his White ex-wife. Polls in the United States showed a striking and consistent pattern: Most Whites believed Simpson was guilty, whereas most African Americans believed he was innocent. Even more interesting, a majority of African Americans (60%) believed that police often frame innocent people, com' pared with less than a fourth of Whites (Streisand, 1995). The perception that Simpson was framed gained credibility when the defense showed that one of the key witnesses, police officer Mark Fuhrman, had made racist comments that he had denied under oath. The jury, having seen an officer apparently lie under oath to help secure a conviction, experienced "reasonable doubt"—what else had the state done? Where did they get the evidence? How was the evidence safeguarded from tampering? Under a cloud of such suspicions, Simpson was acquitted. It is interesting, however, that Simpson was later convicted in civil lawsuits, thus revealing some room for interpretation regarding his innocence (MacNeil/Lehrer Productions, 1997). In short, members of minority cultures who may have been targets of racism or are intimately connected with those who have been should not be viewed as paranoid when they evidence mistrust of mainstream institutions (see Whaley, 1998). Immigrants are also at high risk for being mislabeled with paranoid PD (American Psychiatric Association, 2000a). Faced with language and other barriers and at times with hopelessly arcane immigration rules, the immigrant may become hostile or suspicious; such circumstance-related behavior should not be confused with a character disorder. Most subcultures within 54

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

the United States are more sociocentric than the extremely autonomyfocused mainstream culture. However, minority experiences with racism are likely to engender a certain degree of healthy mistrust of the establishment. The potential impact of culture should not be underestimated. Castillo (1997) discussed Swat Pukhtun culture—a society in which the average male carries a gun, people are genuinely dangerous to one another, and women are kept at home as much as possible to prevent infidelity. Many people in Swat Pukhtun culture would meet the criteria for paranoid PD if judged by U.S. norms, but in fact their response to their situation is adaptive.

STRENGTHS OF PERSONS WITH PARANOID PERSONALITY DISORDER The suspiciously oriented mind is well suited to certain kinds of activities. Counterterrorists, for example, must be able to think like a terrorist, to remain hypervigilant, and to imagine possible deceptive plots that may occur. A bright and creative colleague of mine, warm and sensitive like most psychologists, nonetheless has such a cognitive proclivity. After the tragedy of 9/11 occurred, he shared with me the fact that for years, when he flew, if the pilot stepped out of the cockpit, his heart would jump into his mouth. He confided to me that he could not help but imagine the innumerable dire consequences to which the plane is subject in such moments. Had government officials or airline executives been so "paranoid," tragedy may have been averted. Another acquaintance of mine is able to imagine details of any possible contingency and make adequate preparations. For example, attacked while walking alone in a large city, he was able to frighten off his assailants because he was appropriately prepared and trained. The enormous dividing line between these healthy variants and the person with paranoid PD is the realistic nature of the planning and the lack of what cognitive therapists would call "personalization." Neither of these individuals imagines, as part of their planning or thinking, that such potential attacks are aimed specifically at undermining them; rather, they are trying to be prepared in the event of unlikely, but possible, negative human interactions. Frankly, they are the two people in the world with whom I feel most safe.

TREATMENT PLANNING: SYNERGISTIC TREATMENT The first step in creating catalytic sequences that will help the client is to establish a therapeutic bond. As noted throughout the chapter, doing so is often problematic; a patient and nondirective approach provides the greatest likelihood of success. Within a safe therapeutic relationship, cognitive techniques can help the client to challenge firmly held beliefs about others' maPARANOID PERSONALITY DISORDER

55

EXHIBIT 3.1 Therapeutic Strategies and Tactics for the Prototypal Paranoid Personality STRATEGIC GOALS Balance Polarities Reduce polarity Increase polarity Counter Perpetuations Stop provocations of rejection Modify rigid minidelusions Undo self-protective withdrawals TACTICAL MODALITIES Alter inviolable self-image Moderate irascible mood Reorient cognitive suspiciousness Note. From Personality-Guided Therapy (p. 693), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

licious intents. Behavioral techniques such as skills training can help the client to feel a greater sense of self-efficacy and thus a reduced need for hypervigilance and defensiveness. Interpersonal conceptualizations have obvious relevance, in that the client's main issue is often mistrust of others; helping the client to become aware of the patterns that maintain his or her negative mood and isolating behaviors can be very helpful (see Exhibit 3.1). Such interventions must be carefully timed; introduced too early, they will provoke defensiveness. I find that the ideal timing for helping clients to break out of such patterns is when they express frustration and ask, directly or indirectly, how they can get better. Clients who are depressed are more likely to be able to seek help in such a manner than the nondepressed person with paranoid PD. Medications can be helpful if the client becomes anxious or excessively hostile. If the client's family either participates in maintaining the behavior or bears the brunt of the client's hostilities, family therapy can help to correct those imbalances.

CASE EXAMPLE: JEAN Jean was a 15-year-old girl when her therapist, Kelly Vinehout, first saw her. The client was Caribbean American, the therapist Caucasian, and both were deaf. An incident of petty theft brought Jean to the attention of authorities. She was referred for treatment to a residential group home for the deaf and hard of hearing. Jean had a deaf sister and several hearing brothers and sisters. Her mother was addicted to drugs. Little was known about the 56

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

father, except that he had been in and out of prison and had not been involved with the family for many years. Jean was extremely suspicious and mistrustful, far beyond what could be expected on the basis of normative deaf development or deaf culture. Her paranoia seemed to have been profoundly shaped by isolated traumatic events as well as ongoing social reinforcement. Her first memory was of being about 3 years old and being torn away from her family by the government under the auspices of the child protection division. Jean's fears were then fueled by her older sister's suspicions that the authorities were going to take away everyone in the family, put Mom in jail, lock up all the children, and so forth. With little guidance available from trustworthy adults, Jean was interpreting the world through her 3-year-old eyes and those of her frightened 4-year-old sister. The children were placed in the custody of her grandmother, who was told to not allow contact with the children's mother. However, because the mother lived close by, the children were able to sneak over for visits. This experience encouraged the belief that deceit is an ordinary part of human interactions. For Jean, raised in a home in which the mother was affectionate but routinely neglectful and poorly equipped for parenting, the seeds of paranoia fell on fertile soil. They were watered and nourished by social and interpersonal difficulties at school. Although she attended a school with deaf peers, Jean still did not fit in. Fearful when not in control, she attempted to dominate her social interactions. Although sometimes there is a submissive child around who can form a stable relationship with such a person, this did not happen for Jean; her thinly veiled hostility made it all the less likely that any of her relationships would succeed. Other children would occasionally tease her for being "bossy," not a particularly cruel barb in the world of grade school, but experienced as an infuriating and wounding slur by hypersensitive Jean. All of her relationships in school ultimately failed, leaving her isolated and lonely. On the basis of the nonverbal behavior she observed in the first session, Dr. Vinehout interpreted Jean's stealing, symbolically, as an attempt to secure desperately desired love and affection. Dr. Vinehout turned her attention to Jean's interpersonal relationships. Jean had unusually diffuse boundaries for a girl her age. Hearing children often learn about relationships in a variety of indirect ways—overhearing conversations among older children on the bus ride home, overhearing conversations among adults, and so on. In normative deaf development, children are unable to learn about such matters indirectly and thus rely on direct instruction. Jean's mother and siblings did not provide good role models, and nobody taught her about relationships. Jean tended to be intrusive in gathering information from others and guarded about sharing. Thus she helped to protect herself by minimizing her need to trust others and by gaining information that would help make others more predictable; however, few peers would tolerate that kind of inequity. PARANOID PERSONALITY DISORDER

57

Further, she confused sexuality, affection, and affiliation. Jean was not yet sexually active, but Dr. Vinehout was concerned that her neediness and confusion left her vulnerable to sexual exploitation, which would have cemented her already rigid and paranoid world view. The first goal in treatment was to help Jean to understand appropriate boundaries in relationships. Dr. Vinehout used kinesthetic modeling, with a great deal of modeling and role-play, to help Jean develop more appropriate behaviors. After approximately three sessions, Jean's transference emerged in a rather direct way. The conversation went something like this (translated from the original sign language): jean:

Your hair smells just like my mother's.

Dr. Vinehout: Oh, you wish you had a mom to take care of you. jean:

Yeah, I wish you were my mom.

Dr. Vinehout: I can't be your mom, because then I couldn't be your therapist. For the same reason, I can't be your friend. Here's how it's different.

Dr. Vinehout then went on to explain the therapeutic relationship and how it worked. This kind of directness and bluntness is common and expected in deaf culture. It is also an extremely effective style with troubled adolescents, deaf or hearing, who typically see adult circumlocutions as devious. This early interaction quickly established Dr. Vinehout as someone who was relatively trustworthy, although trust had to be continuously earned throughout the course of a 3-year therapeutic relationship. It is typical for individuals in long-term treatment for PDs to bring most of their quintessential relationship issues into the room as part of the transference—countertransference enactment. In Jean's case, not surprisingly, the central issue was trust. One example was that Jean often asked to see the director of the facility ("Dr. Jones") to try to secure a desired privilege (e.g., permission to buy a bicycle). Dr. Vinehout would write a note to the director, stating the request for an appointment with the director. In Jean's mind, this meant the appointment had already been scheduled. Dr. Vinehout tried to explain that it just meant she would leave a note. Jean would then be disappointed with, and angry at, Dr. Vinehout for failing to make the appointment. So, Dr. Vinehout began to write the note to the director and a reminder note for Jean about what she had committed to do. Still, Jean would believe that someone had altered the note. Jean then got a Palm Pilot, which allowed her to encrypt the note that she wrote to herself (e.g., "Dr. Vinehout will leave a note for Dr. Jones") with a password. The following exchange would ensue: Jean:

You said you'd make an appointment for me, and then you didn't!

Dr. Vinehout: Look in your Palm Pilot. What does it say? 58

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Jean:

"Dr. Vinehout will write a note to Dr. Jones, asking for an appointment."

Dr. Vinehout: Did it say I would make the appointment? Jean:

No.

Dr. Vinehout: Do you see? Jean:

No. All that means is that someone stole my Palm Pilot and changed the note.

Dr. Vinehout: But you made the password yourself. Even if someone took your Palm Pilot, they would not know the password. Jean:

Then 1 must have dreamt the password, and someone must have stolen it from my mind.

Dr. Vinehout: No. That is not what happened. That is what we call paranoid thinking. Nobody can go into your mind and steal your dreams.

This straightforward psychoeducational intervention, repeated numerous times over the years within the context of a deep and secure therapeutic relationship, slowly but surely decreased the number of frank delusions experienced by Jean. Dr. Vinehout also provided Jean with psychoeducation about being Caribbean American in a racist culture. They discussed racial oppression and how that might impact her. Jean was receptive to these discussions. Although confrontation was helpful in a couple of key turning points in the relationship, the key to the success of the treatment was nearly constant validation. Dr. Vinehout helped to place Jean's fears in the context of her genuine experiences, accepting the reality of her ongoing and painful rejection and, more important, unconditionally accepting her as a person. Given her interpretations of events, her painful and ambivalent feelings were understandable; working through such feelings constituted the bread and butter of the twice-weekly individual sessions. In addition to individual sessions, Jean participated in group therapy twice per week. Dr. Vinehout was one of the group therapists along with a male cotherapist. Jean's participation in the group was uneven. At times, she participated well, allowing the peer group to help her process her concerns, such as whether to stay on her medications. Often, however, she was resistant and disruptive, refusing to participate. Her relationship with Dr. Vinehout served to bind her to the group, but jealousy and possessiveness of Dr. Vinehout—for example, when seeing her connect with other clients and with the cotherapist—made the group anxiety provoking. Overall, the group experience was positive for her, but it was not the place in which she made the most progress on her paranoid thinking. Jean's depression was atypical, though the manner in which it was expressed was not unusual for an adolescent, particularly one with paranoid PARANOID PERSONALITY DISORDER

59

PD. She was extremely sensitive to disruptions in her fragile relationships. Rather than becoming sad and anhedonic, Jean would act out. It was predict' able that the day after a perceived slight in therapy or in a friendship relationship she would act out in an aggressive way and get into trouble. Dr. Vinehout's countertransference was unusual in relation to a paranoid client, in part because she seems to have circumvented a fair amount of the projective identification directed her way by the client and because the client tolerated identification of paranoid thinking. Typical countertransfer' ence emotions are feelings of guardedness and defensiveness, to ward off the client's attacks. Dr. Vinehout felt herself pushing away from the client in an effort to set appropriate boundaries; having tapped into the neediness and loneliness underlying the guarded defensiveness, she now had to work hard to set appropriate boundaries and keep the relationship at a healthy distance. In addition to individual and group work, Dr. Vinehout also did family work with Jean's family of origin. She met with the grandmother, uncles, and siblings, focusing primarily on two issues: interacting and communicating. With Jean present, she informed the family bluntly that they needed to know more sign language if they wished to have a relationship with Jean. This intervention helped Jean feel validated, although unfortunately, it did not get the family to learn much more sign language. Dr. Vinehout also helped the family empathize with Jean (e.g., when you sit around and chat, she feels left out and believes you are talking about her). Dr. Vinehout also worked with the family on guidelines for home visits. Jean got no supervision when she was home, which was inappropriate. Although they could not implement suggestions, they did become more aware of why the government agencies were keeping the family apart, and Jean became more understanding and accepting that such a home environment would not be good for her. By the end of the 3 years of treatment, Jean was greatly improved. She was able to function in the residential facility. The frequency of her paranoid delusional episodes had decreased. She had friendly, though somewhat superficial, relations with several of the other residents. Her relationship with the therapist was deep and rich. Although there were still episodes of mistrust, such breaches had been repaired many times, and working through them rather than having the relationship shatter was the expected outcome. Unfortunately, for systemic reasons outside the therapy realm Dr. Vinehout and Jean had to terminate. The termination process followed a predictable course, with Jean unable to process that the relationship would end and an angry confrontation in the penultimate session ("You didn't tell me we had to stop!") despite six consecutive prior sessions of addressing the issue. During the final session, Jean refused to speak with or look at Dr. Vinehout. Dr. Vinehout wrote notes to Jean, outlining the progress Jean had made over the course of treatment, the pride that she (Dr. Vinehout) felt in Jean, and reminders of Jean's plan for the future. During this final session, which consisted of Jean, Dr. Vinehout, and a staff member sitting at the dining room 60

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

table, Jean refused to read the notes. Two weeks later, Dr. Vinehout received a phone call from Jean, stating she had kept the notes and was sorry that she had refused to talk to Dr. Vinehout. In conceptualizing this case from the standpoint of personality-guided therapy, it was clear that addressing the client's paranoid PD was an essential and guiding principle of the treatment. Technically, the core of the treatment was based on client-centered principles of consistent validation of the client's experience. With some clients—for example, those without personality disorders—it is possible to maintain such a stance early in treatment and then enter into a problem-solving cognitive-behavioral format; such was not the case with Jean, nor is it likely to be the case with most individuals with paranoid PD. However, building on this affirmative and validating stance, cognitive and psychoeducational techniques helped Jean to reduce some of her cognitive distortions. Early in treatment, Jean's transference was enacted and became an opportunity to build clarity and trust. Role-playing, which can be considered either a behavioral or an experiential technique, was relied on heavily to prepare Jean for the world of dating and other interpersonal relationships. The focus of much of the treatment was helping Jean establish interpersonal relationships. In conceptualizing the case, Dr. Vinehout drew on the work of Sullivan (interpersonal), Winnicott (object relations; holding environment), attachment theory, and Herman (trauma theory). Dr. Vinehout described therapy as "dancing with the affect" of the client, drawing on the client's subtle nonverbal material as the drumbeat to the music; in that regard, her work reminds me of Virginia Satir's. Synergistically, validation formed the basis of a relationship with the therapist, which then in turn became a platform from which to address other relationship issues, catalyzing the upward spiral of one good turn leading to another. However, the case also illustrates the resilience of the paranoid pattern once set into motion. Despite 3 years of intensive treatment as a relatively young woman, the client still had a good deal of paranoid psychopathology that was interfering with her functioning. She was, nonetheless, much less depressed and generally was feeling and functioning much better.

SUMMARY AND CONCLUSIONS Paranoid PD with depression is a difficult condition to treat because of problems establishing and maintaining rapport. However, in at least some cases, substantial improvements are possible. In the case of Jean, described above, a series of catalytic sequences led to considerable gains. First, the therapist established trust through bluntness and simplicity of speech as well as consistent, persistent use of physical evidence (e.g., the client taking notes in her password-protected computer). Rapport was never taken for granted, and relationship work was undertaken repeatedly. Cognitive techniques (chalPARANOID PERSONALITY DISORDER

61

lenging distorted thoughts) and psychodynamic techniques (e.g., confronting the client's desire for the therapist to be her mother) led to gradual improvements in the client's functioning. Despite the "best practice" ideas and interventions reviewed above, many people with paranoid PD and depression will not be treated successfully. Many will not present for treatment, and others will not form a treatment alliance. Prognosis in such cases is guarded (pun intended). For purposes of personality-guided therapy for depression, empirical research explicitly targeting ways to establish rapport should be a priority, as well as establishing whether depression generally makes the treatment easier (e.g., because of enhanced motivation to relieve the depressive symptoms) or more difficult (e.g., with depression making it more difficult for the person to get mobilized).

62

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

4 DEPRESSION IN SCHIZOID PERSONALITY DISORDER

A good illustration of a schizoid style of relating is shown in the portrayal of John Nash in the film A Beautiful Mind (Howard & Goldsman, 2001). Nash is a math professor, brilliant with numerical and visuospatial patterns, who seems to lack almost completely the capacity to relate to people in any way. He cannot empathize with his students when they have difficulty learning the material, nor can he discern what presentation style might help students to learn more easily or enjoy the material more. He seems to lack the desire to connect or explain. For example, in one scene, a student approaches Nash in his office with a question. He essentially dismisses her and returns to his work. After a few moments of working—a sufficient length of time to be uncomfortable—he looks up and simply observes, "You're still here." His awkward, self-absorbed style is striking, though it does not seem to bother him. Where a more narcissistic professor might disdain students for their "stupidity," the schizoid individual bears no such malice. To him, the needs of the students are merely an enigma—an enigma he may or may not be motivated to solve. Perhaps some of us have had teachers or professors who were similar—writing on the board, with their back to the class, absorbed in the material, and essentially oblivious to the people around them.

63

Notably, even this prototype portrays the more sociable end of the spectrum. The choice to become a professor entails willingness to interact with others; more severely schizoid individuals, if employed, are often late-night security guards or night-shift doormen, back-room mail sorters, and employees at other jobs that entail almost no human interaction. The prototypical person with schizoid personality disorder (PD) has little desire for interpersonal contact, even with family members. Such an individual also has an impoverished cognitive style; that is, his or her understanding, especially of people, lacks richness and vitality. He or she is unable to process the numerous factors that impact people and views his or her own life in similarly simplistic terms. Impoverished cognitive style does not correlate with intelligence; a person with schizoid PD, can, like Nash, have superior abstract reasoning, visuospatial, and verbal abilities. Nonetheless, his or her inner emotional and relational world is simplistic and poorly developed. As noted above, people with schizoid PD are noted for their blandness, flatness, and the lack of desire to connect with others. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa), "The essential feature of Schizoid Personality Disorder is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings" (p. 694). Considered part of the "schizophrenic spectrum" (Siever, 1992), schizoid PD overlaps with the "negative" symptoms of schizophrenia: flat affect, lack of motivation, and social withdrawal. Like individuals with schizophrenia, individuals with schizoid PD may underachieve in social, occupational, or academic arenas. EPIDEMIOLOGY Schizoid PD is a relatively rare disorder. Community studies indicate a low prevalence of schizoid PD. A review of nine epidemiological studies indicates a median prevalence estimate of 0.6% for schizoid PD (Mattia & Zimmerman, 2001). However, the disorder is approximately 9 times as common in treatment settings. A review of eight studies suggests a prevalence rate of approximately 5% in treatment settings, with the prevalence apparently a bit higher in inpatient than outpatient settings (Widiger & Rogers, 1989). DSM-IV-TR described schizoid PD as "uncommon" in treatment settings. This low prevalence has led to a relative paucity of research. As noted by Beck and Freeman (1990), "While there have been extensive theoretical musings about the nature of the schizoid individual, little clinical research has been done on this group. . . . This is not surprising, given the reluctance of schizoid individuals to seek treatment" (p. 122). Unfortunately, little has changed in the intervening 15 years. Thus, the base of clinical lore and inter64

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

vention research is not very deep, and some areas require speculation to elucidate promising, if untested, treatment avenues. In samples of individuals with depression, approximately 0% to 3% have schizoid PD. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), none had schizoid PD, though it is worth noting that there were few individuals with schizoid PD in the entire sample (n = 7). In Pepper et al.'s (1995) dysthymic disorder sample, 2% had schizoid PD. In Fava et al.'s (1995) sample of depressed clients, approximately 3% had schizoid PD. In a sample of 249 depressed outpatients, none were diagnosed with "definite," and 2% with "probable," schizoid PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; none had schizoid PD. Finally, in a sample of 352 clients with both anxiety and depression, approximately 3% had schizoid PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Minimal data are available on the prevalence of depression in individuals with schizoid PD. Zimmerman and Coryell's (1989) study, mentioned above, included a community sample totaling 797 individuals, of whom 143 were diagnosed with PDs. Among the 7 diagnosed with schizoid PD, none met the criteria for major depression.

HOW DO PEOPLE WITH SCHIZOID PERSONALITY DISORDER GET DEPRESSED? Persons with schizoid PD may become depressed when their lifestyle is too remote and detached. They may have a desire for some degree of contact, to fit in meaningfully with others in some way. The sense that life is empty, with no real purpose, is depressing to anyone (Frankl, 1959); the person with schizoid PD, with his or her barren internal world, is prone to such thoughts. In the words of A. T. Beck and Freeman (1990), although usually comfortable with a detached lifestyle, these individuals may become depressed over their awareness that they are deviants who do not fit into society. . . . They may tire of being "on the outside, looking in." Further, their belief that life is meaningless and barren can lead to or exacerbate depression, (p. 129) At times, individuals with schizoid PD may also experience depersonalization, in which they can barely experience their bodies and feel like they are just "going through the motions." Such experiences may be depressing for the individual as well. Thus, schizoid PD likely creates a vulnerability to experiencing depression. As with other PD patterns, people with schizoid PD engage in coping strategies that tend to perpetuate, or even deepen, their original personality SCHIZOID PERSONALITY DISORDER

65

psychopathology. For example, their proclivity to withdraw and remain detached reduces opportunities to learn new interpersonal strategies, thus decreasing the odds that the next relationship will be meaningful and fulfilling. In addition to simple lack of contact, their cognitive impoverishment regarding emotions leads to misinterpretation and oversimplification of others' emotional lives and further reduces the odds that they will have rewarding interpersonal interactions (Millon, 1996). Over time, these strategies and proclivities may lead to a deepening of the schizoid pattern, in some cases to levels that are intolerable even to the person with the disorder. Consistent with the "exacerbation" model (see chap. 2) the patterns associated with schizoid PD and depression "feed" one another, increasing the intensity of both. Schizoid PD and depression overlap in some of their symptoms. The flat, bland presentation of the person with schizoid PD parallels anhedonia in major depression. Lethargic and insipid, such individuals already near the level of psychomotor retardation and fatigue evidenced in depression. Thus there are three symptoms (anhedonia, psychomotor retardation, and fatigue) that are shared to some degree by the two disorders. Dysthymic disorder (which has similar symptoms to major depression but at a lower level of severity and higher level of chronicity) resembles schizoid PD even more closely. It could be that some features of depression and schizoid PD share a common cause, such as brain functioning associated with lethargy and anhedonia. However, in general, people with schizoid PD are not particularly prone to either anxiety or depression. Aloof, but unconcerned about it, the typical person with schizoid PD does not seek therapy. Thus, our focus on the depressed person with schizoid PD represents a unique, and more treatable, subset.

HOW A PERSON BECOMES AND REMAINS SCHIZOID: THEORIES OF SCHIZOID PERSONALITY DISORDER Biological Factors Millon (1981) asserted that schizoid PD, like all personality disorders, has biological underpinnings. He hypothesized that individuals with schizoid PD may have a lack of neural density in the areas related to emotionality, such as portions of the limbic system. He further speculated that there may be problems in the reticular activating system, which is related to the anergia and chronic underarousal of the person with schizoid PD. These neural deficits can be a function of genetics, environmental-biological factors (e.g., anoxia during the birthing process), or environmental-psychosocial factors (e.g., an understimulating social environment). Millon (1996) noted,

66

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

What appears most distinctive about these individuals is that they seem to lack the equipment for experiencing the finer shades and subtleties of emotional life . .. Some interpret their interpersonal passivity as a sign of hostility and rejection; it does not represent, however, an active disinterest but rather a fundamental incapacity to sense the moods that are experienced by others, (p. 218)

The above quote implies the neurological deficits previously described. Millon (1981) conjectured further about how biological and psychosocial factors may interact to deepen the biological problem: Another frankly speculative hypothesis is that a substantial number of adult schizoid personalities displayed low sensory responsivity, motor passivity, and a generally placid mood in infancy and early childhood. They may have been easy to handle and care for, but it is likely that they provided their parents with few of the blissful and exuberant responses experienced with more vibrant and expressive youngsters. As a consequence of their undemanding and unresponsive nature, they are likely to have evoked few reciprocal responses of overt affection and stimulation from their caretakers. This reciprocal deficit in sheer physical handling and warmth may have compounded the child's initial tendencies toward inactivity, emotional flatness, and general insipidity, (p. 292)

This process may be further compounded if, assuming the schizoid tendency was inherited from one or both parents, the spontaneous and persistent expression of warmth from the parents may have been lacking in any case. Research suggests individuals with schizoid PD are more likely than comparison groups to have a history of neglect (Lieberz, 1989). Genetic Factors

Genetic studies in the phenomenologically similar autistic spectrum disorders may bear fruit for understanding schizoid PD. Asperger's disorder, the core feature of which is "severe and sustained impairments in social interactions" (American Psychiatric Association, ZOOOa, p. 80), seems especially closely tied to schizoid PD. There is strong support for a genetic basis of autistic spectrum disorders using twin studies (Bailey et al, 1995; Steffenburg et al., 1989), and research is ongoing to discover specific genetic markers (Auranen et al., 2002; Buxbaum et al., 2001; Liu et al., 2001). There is also evidence of an increased rate of schizoid PD in the parents of people with autism (Narayan, Moyes, & Wolff, 1990). Schizoid PD is heritable, apparently at similar levels to other personality disorders. Like an array of thoroughly studied normal personality traits (Loehlin, 1989), PDs typically have a heritability estimate of .40 to .60. Coolidge, Thede, and Jang (2001), in an investigation of personality disorders in 112 twin pairs ages 4 to 15, found that h2 for schizoid PD was .73; the range for all personality disorders was .50 to .81. A study by Torgersen,

SCHIZOID PERSONALITY DISORDER

67

Onstad, and Skre (1993) found a heritability for schizoid PD of .29. Genetic factors accounted for approximately 50% of the variance in dimensional measures such as social avoidance (Livesley, Jang, Jackson, & Vernon, 1993), restricted expression, and inhibition and for 38% of the variance in affect constriction (for a review, see Jang & Vernon, 2001). Similarly, Eysenck's extraversion construct (of which schizoid PD would represent the extreme low end) is moderately heritable (Nigg & Goldsmith, 1994). Genetic studies have generally supported the notion that schizoid PD is part of the "schizophrenia spectrum" (Siever, 1992). However, although studies of schizotypal PD have consistently linked the disorder to schizophrenia, studies examining the genetic connection between schizoid PD and schizophrenia have been somewhat inconsistent (for a review, see Nigg & Goldsmith, 1994). It is likely that schizoid PD is related to schizophrenia but not as strongly as schizotypal PD; this conceptualization is consistent with Meehl's (1990) contention that cognitive slippage is the central component of schizotypy. Medications Despite a significant effort, I could locate no specific studies on medications for schizoid PD. A study by Ekselius and von Knorring (1998; see chap. 1 for a review) found that the antidepressants sertraline and citalopram, both selective serotonin reuptake inhibitors, led to an increase in the diagnosis of schizoid PD, although there was no increase in the number of criteria met on a structured interview. I cannot explain this odd finding. The number of schizoid patients was so small (1 pre- and 6 postintervention) that one should be cautious in interpreting the results. There are some underlying dimensions or symptoms that may be amenable to psychopharmacological interventions. In the absence of further data, it is worth considering Joseph's (1997) speculations based on his clinical experience. He argued that schizoid PD is reminiscent of the negative symptoms of schizophrenia. Newer, atypical antipsychotics have the best efficacy with deficit syndromes; thus clozapine, olanzapine, sertindole, and risperidone would be the most likely to benefit people with schizoid PD. These medications may help the patient to become more sociable and emotional. Joseph conceptualized the anhedonic and low-libido features of schizoid PD as having biological underpinnings similar to those of the same symptoms in a person with depression; he recommended an energizing medication such as bupropion. As in cases of Axis I social anxiety, individuals with schizoid PD who experience anxiety in social situations may benefit from selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or anxiolytics. Although Joseph's speculations were reasonable, they are not currently backed by scientific research. There is no substitute for appropriate empirical studies, ultimately leading to randomized clinical trials.

68

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Psychological Factors When considering the person's psychological functioning, important areas to consider include his or her learning history; thoughts, feelings, unconscious motivations; and relationships. The schools of thought described below (e.g., cognitive-behavioral, humanistic, psychodynamic, interpersonal, and family systems) emphasize different aspects of the person's functioning and will be described in turn. Millon's Theory According to Millon (1969/1985, 1981, 1996, 1999), individuals with schizoid PD represent the "passive-detached" type. They are thought to have a generally bland, passive nature, perhaps because of impoverished neurological substrates associated with emotion. These neural deficits in adulthood may have been caused by genetics or shaped by experience. The early experiences of people with schizoid PD are likely to be characterized as dull and colorless, although extreme withdrawal by caretakers could account for development of schizoid PD in a person who lacks a strong predisposition to the disorder. Severe difficulties in relating, such as reactive attachment disorder, that are frequently seen in children raised in neglectful or abusive orphanages exemplify the potentially profound impact of extreme environmental conditions (Hall & Geher, 2003; Wilson, 2001). At a less intense level, a temperamentally placid child, exposed to minimal "stimulus nutriment" (i.e., environmental stimulation; Millon, 1981), is at risk for developing schizoid PD. Excessively formal relationships with one's parents can have a similar effect. Deutsch (1942), describing the "as if" personality, gave the example of a child born to royalty. Raised by a variety of nannies, he had only brief and occasional contact with his parents. At that time, he was required to profess his love for them, whereupon he was dismissed. It is not surprising that this child manifested disturbed interpersonal relationships (Deutsch, 1942, cited in Millon, 1981, p. 294). The description of the person with schizoid PD in terms of Millon's domains is presented in Appendix B. Of the characteristics listed, "unengaged interpersonal conduct" and "apathetic mood/temperament" are the most salient features. Cognitive-Behavioral Conceptualization and Interventions Cognitive-behavioral therapists emphasize dysfunctional thought and behavior patterns that underlie disorders. Dysfunctional attitudes that are common to people who are categorized as having schizoid PD are listed in Exhibit 4.1. Such thoughts contribute to the individual continuing to live in a withdrawn, isolated manner. The clinician can explore for these and simi-

SCH/ZOJD PERSONALITY DISORDER

EXHIBIT 4.1

Attitudes and Assumptions Typical of a Person With Schizoid Personality Disorder * People are replaceable objects. Relationships are problematic. Life is less complicated without other people. Human relationships are just not worth the bother. It is better for me to keep my distance and maintain a low profile. * I am empty inside. * I am a social misfit. * Life is bland and unfulfilling. * Nothing is ever exciting. Note. Asterisks indicate items that suggest depression as well. From Cognitive Therapy of Personality Disorders (p. 128), by A. T. Beck and A. Freeman, 1990, New York: Guilford Press. Copyright 1990 by Guilford Press. Reprinted by permission.

lar thoughts and attitudes and then challenge them using Socratic dialogue (J. S. Beck, 1995) or disputation (Dryden & DiGiuseppe, 1990; Ellis, 1995). Dysfunctional thought records have been found to be helpful for people with schizoid PD (A. T. Beck & Freeman, 1990; A. T. Beck, Freeman, & Davis, 2004) and in depression (J. S. Beck, 1995). Not only do dysfunctional thought records challenge dysfunctional thoughts, but they also teach gradations in thinking, helping clients to overcome all-or-none thinking. Individuals with schizoid PD may believe they must always be alone, or that they never care about what happens. Dysfunctional thought records help to challenge those beliefs, often leading to awareness that such individuals do sometimes prefer to be with others or that they do sometimes care. Individuals with schizoid PD, almost by definition, lack social skills. Assuming they are depressed because they are too isolated, even given their rather minimal needs, then skill building may be extremely helpful. Liberman, DeRisi, and Mueser (1989) provided excellent guidelines, designed primarily for individuals with serious and persistent mental illness (e.g., schizophrenia and mental retardation) but adaptable to the person with schizoid PD. Excellent guidelines for couples are available in A Couple's Guide to Communication by Gottman, Notarius, Gonso, and Markman (1976); because the book is written in lay language, it can be assigned to the couple as bibliotherapy. Social skills can be taught using role-playing, in vivo exposure, and homework. Group social skills training has the obvious advantage of allowing practice with other clients rather than only the therapist. The client can also be assisted to attend to positive emotions. Individuals with either depression or schizoid PD will have a tendency to attend to negative thought patterns; an individual with both disorders will experience this even more. Homework assignments such as journaling at least one positive thought per week (at first) then per day (later on) will help the person to challenge automatic thoughts such as "life is bland and unfulfilling."

70

PERSONALITY^ U1DED THERAPY FOR DEPRESSION

Assertiveness training (Alberti &Emmons, 1978; M. Smith, 1975) can help depressed persons with schizoid PD to overcome their passivity and perhaps get some more of their needs met. A unique challenge with persons with schizoid PD is their perception that they have almost no needs. Selfawareness work would be useful, perhaps even essential in this regard. Meditation training (Kabat-Zinn, 1990, 1994; LeShan, 1974; Murphy & Donovan, 1997) and focusing training (Gendlin, 1978) are methods by which the individual can be taught to focus on feelings, perhaps gaining more richness to his or her rather impoverished internal environment. As discussed in chapter 2, exercise is a natural antidepressant. Naturally sluggish, depressed individuals with schizoid PD would benefit greatly from the energizing aspects of exercise, though for exactly that reason they may be unusually resistant. As always, motivation is the key. Patience on the part of the therapist is also critical; the suggestion should be well timed. One effective way to introduce the topic is to bring it up in a brainstorming session if the client asks, "What can I do about my depression?" If that does not occur, then at some point asking if the client is aware of how helpful exercise can be in reducing depression would help the exercise "precontemplator" to become a "contemplator." Sex therapy can also be useful for individuals with depression and schizoid PD. Most individuals with schizoid PD have weak sex drives, and in major depression sex can become not only uninteresting but even aversive (A. T. Beck, 1983). At such times, it is best to treat the depression and wait a bit before encouraging sexual behavior. When a clinician fails to assess the impact of depression on sexual feelings and behavior, it can have a negative impact on the therapeutic relationship, as illustrated by author William Styron (1992) in his book Darkness Visible. Styron, in the midst of a severe depression, was nearly suicidal, thoroughly anhedonic, and had great difficulties sleeping. His psychiatrist, pseudonymously referred to as "Dr. Gold," was switching medications to Nardil, after an unsuccessful trial of two other medications: Further, Dr. Gold said with a straight face, the pill at optimum dosage could have the side effect of impotence. Until that moment, although I'd had some trouble with his personality, I had not thought him totally lacking in perspicacity; now I was not at all sure. Putting myself in Dr. Gold's shoes, I wondered if he seriously thought that this juiceless and ravaged semi-invalid with the shuffle and the ancient wheeze woke up each morning from his Halcion sleep eager for carnal fun. (p. 60)

Of course, the psychiatrist was merely being ethical by informing the patient of potential side effects; nonetheless, Styron experienced the intervention as unempathic because, apparently, the physician had not sufficiently contextualized the discussion in light of the patient's ongoing experience. Keeping that cautionary tale in mind, sex therapy can be extremely useful in

SCHIZOID PERSONALITY DISORDER

71

many cases in which the mildly to moderately depressed person with schizoid PD is in a relationship. Although not as interested in sex as others, individuals with schizoid PD often "don't mind" having sex, and those whose schizoid symptoms are sufficiently mild for them to be in a relationship are typically also sufficiently interested in the other person to go to at least some lengths to try to please him or her. Sex therapy can help enhance pleasure as well as sensitivity to the other person's needs—two areas in which the person with schizoid PD is likely to have problems. Several fine books are available for adjunctive bibliotherapy with sex therapy (e.g., Sexual Awareness [McCarthy & McCarthy, 1984] or The Gift of Sex [Penner & Penner, 1981]). Client-Centered, Humanistic, and Existential Therapies Client-centered, humanistic, and existential therapists eschew a diagnostic or labeling'based approach, and thus there is little, if any, clientcentered or humanistic literature specific to schizoid PD. Rather, in these approaches, the therapist would look at the ideographic aspects of the case. Nonetheless, a prototypical person with schizoid PD, coming from a background of relative neglect and often with stunted or excessively formal relationships with important others such as parents, represents almost a sine qua non of the thwarted actualizing tendency (Rogers, 1979). The clientcentered therapist would focus on creating the conditions for growth, a nonjudgmental space in which the client could explore his or her feelings, and on reengaging the actualizing tendency. If the client wished to, past relationships could be explored, which would then yield information about the conditions of worth to which the child was exposed. Client-centered therapy is somewhat passive by nature; the initiative must come from the client. Some individuals with severe schizoid PD have such problems with initiative that a modification of the therapy developed by Prouty (1994) would be helpful. Prouty labeled his approach "pretherapy" to indicate a process that would prepare a client for traditional therapy. However, his case studies suggest that the process has therapeutic effects (sometimes dramatic ones) in its own right. It was developed for individuals with severe communication problems, such as autism or severe mental retardation, and psychoses. Pretherapy uses concrete empathy, in which the therapist mirrors exact words and bodily movements to establish contact. The therapist can also simply make observations, which may help the depressed and severely schizoid client. For example, the therapist might observe, "You are sitting with your hands in your lap," or "You are remaining quiet," or "You are looking into my eyes." Such interventions can establish contact with a client with whom it is difficult to connect. Other, more dramatic techniques may be useful for the person with depression and schizoid PD. Gestalt therapy—for example, the empty chair technique—can be used to uncover any feelings regarding difficult relationships or feelings of neglect from childhood. Care should be taken not to over72

PERSONALITY-G VIDEO THERAPY FOR DEPRESSION

whelm the client; unaccustomed to emotional arousal, the person could experience substantial anxiety. A solid therapeutic relationship should be established before using experiential techniques, which would thereby allow the therapist to provide support if the emotions do become overwhelming. Self-awareness techniques may be a direct and substantial form of healing for the emotional deficits of the person with schizoid PD. Mindfulness meditation (Kabat-Zinn, 1990) has been shown to be a powerful intervention to decrease depression (Kabat-Zinn et al., 1992), and participants have reported substantial improvements in their bodily and emotional selfawareness (e.g., Broadwell, 1998; Kabat-Zinn, 1990). Focusing (Gendlin, 1978) similarly induces increased body awareness, as well as self-awareness with regard to thoughts and feelings. For the depressed person with schizoid PD, these improvements can be invaluable. For clients who lack a sense of purpose, existential therapy (May, 1983b) or logotherapy (Frankl, 1983) can help in exploring the meaning of life. Based more on an attitude or philosophy than on a set of techniques, existential approaches consider the fundamental anxiety that one confronts to be existential anxiety—the awareness that our existence is finite and that there is always a threat of nonbeing or nonexistence. Frankl (1983) suggested that the client who presents with a sense of or fear of life being meaningless should be commended on having the insight and courage to confront that issue and told that many go through life "going through the motions," without ever contemplating life's meaning. The question, "What is the meaning of life?" is unanswerable; Frankl (1959) observed that it is like trying to answer the question, "What is the best color?" The answer, of course, is that it depends on the context and the person; each person must find his or her own meaning in existence. Other questions that help get at meaning in the client's life include Linehan's intervention, designed for suicidal borderline clients but broadly applicable in its underlying message. In the video Treating Borderline Personality Disorder (Linehan, 1995), a client stated that she was suicidal. Linehan replied, irreverently, "So, why don't you kill yourself right now?" For the existentialist, that is, in fact, the exact question. If life has no meaning, then why live? With the possible exception of, "Because I'm afraid it will hurt," virtually any answer addresses the meaning the client finds in life. If the client replies that it would be too painful for a relative or friend to bear, then she is living for love. If the client replies that she believes that therapy is worth a try and things may get better (as the client actually does in the video) then she is living for hope. And if she replies that she wants to live because there is one more thing she has to do, then she is living for commitment. Ultimately, commitment to something that one believes is more important— higher, if you will—than oneself is where many people find meaning. Bibliotherapy can stimulate clients in the search for meaning. Books such as Don't Sweat the Small Stuff (Carlson, 1997), The Mirack of MindfulSCHIZOID PERSONALITY DISORDER

73

ness (Nhat Hanh, 1976), and Wherever You Go, There You Are (Kabat-Zinn, 1994) all are useful jumping-off points to encourage clients to look at life a bit differently. Simply assigning a client to read at least a few pages and then asking if there was anything that he or she found meaningful can lead toward the client's central concerns and hopes. Psychodynamic Therapy

In discussing schizoid PD, psychoanalytically oriented writers generally have emphasized anxiety rather than depression as more central to the disorder. Klein (1946/1996) believed splitting was the essential characteristic of the schizoid condition. In her view, in normal development the child experiences persecutory ideation, which is the projection of the child's innate aggression onto the mother or, more specifically, onto the part of the mother with which the infant has direct contact (the "bad breast"). Splitting, which Klein defined as the separation of conflicting self and object representations, is a defense against the anxiety generated by the persecutory ideation. The schizoid individual failed to resolve these conflicts and therefore remained with a narcissistic orientation, including the need to control others and the tendency to either cling to or withdraw from them. Thus the apparent absence of anxiety in the schizoid individual was an illusion; rather, as Klein (1946/1996) hypothesized, the anxiety is kept latent by the particular method of dispersal. The feeling of being disintegrated, of being unable to experience emotions, of losing one's objects, is in fact the equivalent of anxiety. This becomes clearer when advances in synthesis have been made. The great relief which a patient then experiences derives from a feeling that his inner and outer worlds have not only come more together but back to life again. At such moments it appears in retrospect that when emotions were lacking, relations were vague and uncertain and parts of the personality were felt to be lost, everything seemed to be dead. All this is the equivalent of anxiety of a very serious nature, (p. 21)

Fairbaim (1952) emphasized the early-childhood maternal relationship in the development of schizoid PD. He noted the following: (i) that in early life they gained the conviction, whether through apparent indifference or through apparent possessiveness on the part of their mother, that their mother did not really love and value them as persons in their own right; (ii) that, influenced by a resultant sense of deprivation and inferiority, they remained profoundly fixated upon their mother; (iii) that the libidinal attitude accompanying this fixation was not only characterized by extreme dependence, but also rendered highly self preservative and narcissistic by anxiety over a situation which presented itself as involving a threat to the ego; (iv) that through a regression to the attitude of the early oral phase, not only did the libidinal cathexis of an already internalized "breast-mother" become internalized, but also the 74

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

process of internalization itself became unduly extended to relationship with other objects; and (v) that these resulted in general overvaluation of the internal at the expense of the external world, (quoted in Akhtar, 1987, p. 503)

As a result of these processes, these individuals take rather than give in their emotional lives. Further, emotional contacts exhaust them because they defend against their difficulties in giving by playing roles. Love itself is viewed as dangerous, a consequence of the early experiences noted above, and thus they defend against loving both themselves and others. Fairbairn (1952) further noted that those with schizoid personalities are drawn to the arts as a way of having indirect contact with others and showing the self but at a safe distance. O. F. Kernberg and colleagues (Clarkin, Yeomans, & Kernberg, 1999; O. F. Kernberg, 1967; O. F. Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989; Yeomans, Clarkin, & Kernberg, 2002) included schizoid PD in a conceptualization of borderline personality organization. Like Klein and Fairbairn, Kernberg viewed splitting as the fundamental defense mechanism of the schizoid character type. Poor ego development leads to a chronic sense of unreality, which, combined with dispersal of affect, leaves the schizoid individual feeling chronically empty. Kernberg (1970) considered the schizoid personality to be a "low" level of personality organization, indicating that it is next to the psychotic range of functioning. Kernberg's "transference-focused psychotherapy" (Yeomans et al, 2002) uses the traditional analytic techniques of clarification, confrontation, interpretation, and technical neutrality. The sine qua non of his treatment, however, is analysis of the transference in the here and now. Although in his writings he generally emphasized confrontation over nurturing support, Kernberg artfully combined his confrontations with accurate and emotionally attuned statements. The following case appears, at least in this fragment, to involve a mixture of schizoid and dependent features—a person with "pure" schizoid PD as defined in DSM-IV-TR would not particularly expect or want the therapist to care. Nonetheless, the patient's startling self-absorption and lack of empathy and relationship skills are consistent with schizoid pathology. Therapist: Patient: Therapist: Patient:

Therapist:

I notice that you're making some marks on your pad whenever I speak. Yes, I'm counting how many times you talk. Why do you do that? It helps me know if you care about me. I count up the number of times you speak, and when I go home I compare that number to the last session. That's how I tell how much you're giving me. Does it matter what I say? SCHIZOID PERSONALITY DISORDER

75

Patient:

Not so much. What really counts is how many times you tell me why you think I'm doing what I'm doing. Then I know you're really listening to me and concerned about me.

Therapist:

So it's very important that I care about you, and you've devised a scheme to answer that question for yourself. Can you see you're also treating what I'm saying as if it were worthless? (O. F. Kernberg et al, 1989, p. 115)

This fragment is an illustration of several key aspects of Kernberg's approach. Kernberg used both clarification and confrontation regarding the relationship between the therapist and the client (i.e., the transference) to push the client to integrate the split self and object relations implied in the interaction. Persons who have both depression and schizoid PD would presumably be those who have experienced and processed the object loss, at least partially, rather than splitting any negative emotions off completely. Depression generally entails the necessity of whole object relations. To the extent that they use neurotic defenses rather than splitting, they are more in touch with reality. Thus, although they experience more psychic pain, depressed persons with schizoid PD are likely functioning at a somewhat higher level. This conceptualization is consistent with clinical experience—individuals with schizoid PD and depression are more likely to profit from therapy than "pure," emotionally absent, prototypically schizoid individuals. In sum, the psychodynamic approach emphasizes that the superficial symptoms of schizoid PD are not to be trusted—that in fact the person's blandness is a defense against deeper anxieties. These anxieties are rooted in early trauma, particularly in relation to the mother, who is seen as withdrawing and abandoning. If one can, through appropriate analysis, resolve the inner conflicts and underlying anxieties, then the person will experience tremendous relief. The recommended treatment involves traditional psychodynamic techniques, such as technical neutrality, confrontation, and analysis of the transference. Depression, from a psychodynamic perspective, is likely to be rooted in object loss; in the case of the person with schizoid PD, a common scenario would be the withdrawal of the mother, whether because of her own problems with intimacy, physical illness, or mental disorder. Once the depression and the schizoid withdrawal are properly analyzed, the client will then become more mature, flexible, and related. It is apparent, however, that theorists from a psychodynamic perspective are talking about a somewhat different patient population. Akhtar (1987), in his review, noted the similarity of the psychodynamic interpretation of the schizoid personality and avoidant personality disorder. It could be that case studies of "schizoid" individuals reflect aspects not only of schizoid but also of avoidant and paranoid disorders. From Millon's perspective, it is certainly the case that the analysts are using the term schizoid in a different 76

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

manner than he is. Millon (1996) noted that essentially, there is not much to analyze within the prototypical schizoid PD and focused on other techniques. That observation notwithstanding, it is also true that most people with PDs are better described as having admixtures of two or more personality disorders: schizoid-dependent, schizoid-avoidant, or schizoid-obsessivecompulsive. Although the person with "pure" schizoid PD may be unanalyzable, many of the schizoid subtypes would be analyzable. Thus the clinician must be careful about generalizing across different conceptualizations. Family Systems In this section, I conceptualize the situation in which the depressed person with schizoid PD is an adult and is either coming in for marital therapy with a spouse or for family therapy with his or her parents. The latter case occurs with some regularity for clients with other severe mental illnesses such as schizophrenia. The subsequent section, on children, includes family interventions in which the schizoid client is a child. There are several ways of viewing families in relation to schizoid PD: (a) The family behaviors or dynamics contributed significantly to causing the disorder, (b) the family is a victim of a primarily biological disorder and is coping with it as best they can, and (c) biology and family dynamics combined to produce the disorder (an interactionist perspective). Although the interactionist perspective is compelling, it is useful to note that all three models are partially correct and that each model will be the best explanation in a certain percentage of the cases. It is most likely that the family will view the second model—that "this is just the way he is and the way he always has been"—as the most accurate and useful. To the extent that the therapist uses one of the other two models, there is a risk of incongruence with the family, which could lead to premature termination or other problems. In cases in which there are clear biological signs, such as vegetative signs of depression and a strong history of schizoid behavior from early in life, emphasizing biological aspects of both disorders is likely to facilitate an appropriate and rapid bonding process with the therapist. In such cases, it is likely that the ultimate adjustment of the family will involve letting go of fantasies that the person with schizoid PD can be—or already is—in the average range of emotional sensitivity. The son who is disappointed with his depressed and schizoid father will feel better if he can accept his father's limitations. As mentioned previously, many clients are aware that biological factors contribute strongly to depression and will thus be comfortable with such a conceptualization. Few, however, are familiar with the concept of PDs, much less a biological component for a specific one. The risk of emphasizing biological considerations is locking the identified patient into the role of the "pathological one"; this can and should be undone by emphasizing the individual's strengths and relating to the family in a

SCHIZOID PERSONALITY DISORDER

77

manner in which each individual's competencies—including those of the identified patient—are allowed to shine. The decision as to whether to share the diagnosis that the person has schizoid PD should be made on a case-by-case basis. Some basic psychoeducation, such as noting, "We now know scientifically that people are born with a wide range of abilities in sensing other people's emotions, getting emotionally involved, or getting excited about things," will suffice in many cases. In other cases, the label will provide a rallying point around which the family can get information, help, or support. If the label will disempower a family member—for example, if the person with schizoid PD is one of the parents—then it may be better to avoid using it. This stands in contrast to my approach to borderline PD, in which I virtually always share the diagnosis with the client. There is a great deal of information available on borderline PD, including several books that are written in lay language, numerous Web sites, and a national support organization. None of these are available for schizoid PD, so sharing the label does not have the same builtin practical advantages. In cases in which parents are bringing in their child with schizoid PD, sharing the diagnostic label, along with its similarity to autistic spectrum disorders, may allow the parents to tap into a crucially important social support network. A number of different patterns may emerge in a family system with parents and children in which the identified patient (the person with schizoid PD and depression) is one of the parents. From a structural perspective (Minuchin, 1974), the family is most likely to be disengaged. Boundaries are likely to be rigid between the identified patient and everyone else in the family. If the spouse has a similar character structure, then the entire family may be distant and disengaged. Marriages in which one partner has schizoid PD and depression may be dominated by feelings of being "together, but alone" (Moultrup, 1985). However, assuming the other spouse has a complementary personality, such as a more engaging temperament or dependent qualities, cross-generational boundaries may become blurred as the emotional needs of the parent are satisfied through the children. Thus, for example, the presence of a schizoid and depressed mother would encourage the oldest daughter to become parentified and provide caretaking for the other children; role reversal may also occur, in which the oldest daughter takes care of the father. If one or more of the children feel neglected, then there could be a variety of acting-out behaviors, potentially serving several functions within the family. The acting-out behavior may express rage over feelings of being neglected or may inject some purpose into the parents' lifeless marriage, thus keeping the family together. Paradoxical techniques are very powerful and should be used judiciously, but they can be effective in cases in which one spouse has schizoid PD and depression. "Prescribing the symptom" (Haley, 1963; L'Abate, Ganahl, & Hansen, 1986; Palazzoli, 1988) has been defined as telling the 78

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

family to continue doing what it is already doing. If the family complies with the therapist, then they have taken a step toward collaborative work. On the other hand, if they change, then, by definition, they become unstuck. In most cases, the intervention is low risk; they are not likely to get worse from being instructed to continue their current behavior, and they may improve. The positive connotation technique, a particular form of symptom prescription, can be helpful in breaking through feelings of "stuckness" in a family (Palazzoli, 1988). Although using what is labeled a paradoxical technique, in fact the therapist is describing in an extremely straightforward fashion the function he or she believes the symptoms are playing in the family. The intervention stresses the role of each individual in the family in maintaining the family system. Thus, for example, consider a family in which there are a husband, wife, and two teenage children and in which the father has depression and schizoid PD. Consider the prototypical situation in which the wife is feeling overburdened and one or more of the children are beginning to act out, for example by breaking curfew. The therapist conceptualizes the problem as one in which there is isolation and distancing on the part of the father but poor differentiation of each member of the family, leading to painful maneuvering to attempt to establish acceptable levels of closeness with one another. The therapist might assign homework as follows: Dad, you should continue to complain about feeling depressed and continue to lie around the house as you have been doing for the past 3 weeks. This gives Mom an opportunity to feel strong and helpful and gives the children an opportunity to become more independent. This rather dramatic highlighting of the functions served by the symptoms encourages the family to consider other, less painful ways of getting their needs met. It sidesteps certain aspects of resistance because the therapist is not pushing for change. If the family "resists" and changes anyway, so much the better. If they stay the same, then they have done so at the request of the therapist and may be willing to try other experiments to resolve their problems; further, the reconceptualization of their problem, focusing on positive aspects of the symptoms, generally sparks fresh ideas for the kinds of changes to which they would be open. Family sculpture techniques (L'Abate et al., 1986; Satir, 1983) are also powerful and may be particularly helpful to the person with schizoid PD who has strong spatial abilities and spatial reasoning. Family sculpting has been defined as a method in which family members are asked to arrange one another as a living statue or tableau. Drawing upon their creative instincts, and using such nonverbal dimensions as distance, posture, visage, and gesture, the family members give concrete representation to their impressions of the family. (L'Abate et al., 1986, p. 166) SCHIZOID PERSONALITY DISORDER

79

The sculpture may also be put in motion, which in many cases adds important information: Another choice at this point can be to have the sculptor put the whole sculpting in motion before verbally processing what has been sculpted. . . . With static sculpting one gets a sense of family boundaries and alliances but not the rules for traffic flow. With dynamic, or moving, sculptures one can see traffic flow and also have the chance to see action sequences repeated in time, producing a more dynamic representation of family stuckness and rigidity and family rules. (L'Abate et al., 1986, p. 180)

Reliving moments or sequences from the past or spatially representing relationship issues can be most enlightening to the client and may produce powerful insights. If even such a high-impact technique as family sculpture produces relatively little emotional impact on the person with schizoid PD, it may allow the client a clearer understanding of how his or her partner feels and thus lead to more appropriate or attentive behavior. Some people with Asperger's disorder describe a process of attending to another, consciously modeling their behaviors in order to be more accepted and acceptable (Willey, 1999). The passivity and lack of strong feelings of persons with schizoid PD can be an asset in this regard; being generally passive, they may not mind doing certain things differently, because it is "all the same" to them.

COUNTERTRANSFERENCE The literature on countertransference responses to individuals with schizoid PD is extremely limited. Giovacchini (1979) noted feelings of "existential terror," or a primitive fear of nonexistence that often led to feelings of hopelessness, with his schizoid patients (similar to modern schizoid and schizotypal PDs). Robbins (1998), referring to the "autistic position," discussed countertransference responses such as a feeling of vagueness and disconnection in response to the client's devastating isolation. Sadness, perhaps related to pity, also becomes prominent. Rosowsky and Dougherty (1998) noted how substantial feelings of disconnection, worry, and inadequacy occurred among individuals treating a man with schizoid and schizotypal traits who frequently fled his inpatient medical hospitalizations. A. T. Beck et al. (2004) noted that therapists may have a difficult time when clients have substantially different values from theirs. For example, the person with schizoid PD may have little interest in relationships; those of us who have chosen clinical psychology as a profession are likely to put relationships at a premium. A. T. Beck et al. recommended that therapists challenge their belief that their own way of looking at the world is the only valid one and to try to imagine the world from the client's perspective. 80

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

In accordance with the observations above, research on graduate students suggests that they initially respond to individuals with schizoid PD with feelings of compassion and sympathy, but also pity and disconnection. Many respond with feelings of sadness or downheartedness, even when the client does not appear to be particularly depressed (Bockian, 2002a); perhaps this is related to the conflict in values discussed by A. T. Beck et al. (2004), which was reviewed above. Considerable anxiety is generated in some students, apparently because of concerns that they will not know what to say to the person and therapy will grind to a halt. Experienced therapists probably feel the same way at times, although 1 suspect many of us feel what the average person feels in response to people with schizoid PD: boredom (Millon, 1996). The dullness, the impoverished descriptions of others, and the satisfaction with a bland, colorless existence can lead to a subdued therapeutic environment, one that is nonetheless appropriate and received positively by the individual with the disorder. I also recall my work with people with brain injury. Often, other people would get angry with the person who was brain injured for being "lazy." It was clearly the case that some people with brain injury would become apathetic and unmotivated. It struck me that concepts with a strong moral valence, or ones that we might attribute to a person's self or even his or her soul, are mediated by the brain. A person who becomes apathetic after brain injury may not merely be "not trying"; it could be that the physiological apparatus that underlies motivation has been damaged. Certainly, this poses a challenge—perhaps an insurmountable one—to the physical or occupational therapist who is trying to help the person return to functioning. However, recognition of damage to the motivational system conceptually changes the therapy: Therapy consists of undertaking exercises that will help to repair the motivational system itself. In the United States, people place great value on "trying." Probably each and every one of the hundreds of millions of students who have passed through the public education system has heard, particularly in the younger grades, "Whether you do well or poorly, it's okay, as long as you tried your best." The ability to try is itself taken for granted as a lowest common denominator. If Millon's theory (Millon, 1981, 1996) about the brain structures and functioning of people with schizoid PD is correct, then their capacity to try, to be effortful, to engage in motivated behavior is itself reduced. Recognizing that the person is confronting an unusual biological challenge often helps the clinician to reduce feelings of frustration. Therapist emotional reactions can also be a wise guide regarding the therapeutic contract. Although it is often wise to reduce session length and frequency, if this is an inappropriate avoidance of a person who is truly distressed then such avoidance is a harmful countertransference that demands supervision or peer consultation. However, in many cases, it is part of an appropriate plan. Feelings of frustration can often help to guide me in this regard. The person with schizoid PD may have rather modest goals for imSCHIZOID PERSONALITY DISORDER

81

provement, and change may be very slow. If the therapeutic goal in supportive or behavioral therapy, for example, involves interacting with others, and it takes the client 10 days or so to hook up with someone else, then a biweekly session will feel more fruitful to both parties than the more typical weekly sessions. Of course, there are therapies that involve no explicit or implicit demand to change (e.g., client centered and existential), and in psychodynamic therapy, there is so much material to cover from the past as well as so much to process in the transference that frequent, full-length sessions are appropriate. When working with someone with schizoid PD, collaborative goal setting is extremely important. It is all too easy to project our own needs or desires onto the person. We therapists were likely drawn to this field because we value relationships and have high levels of empathy with others. We likely see warm relationships with others as healthy, and the cooler, more detached relations of people with schizoid PD as problematic. We may therefore jump to conclusions about the nature of the problems of individuals with schizoid PD. We may view their isolation or lack of intimate relationships with others as devastating or pathological. The clients, however, may see things very differently. They may have little desire to interact with others, much less pursue close relationships. Thus we must carefully assess individuals and work with them to uncover their goals and motivations. Therapist lack of congruence with a client's goals can lead to premature termination and a negative attitude toward therapy.

SOCIAL CONSIDERATIONS AND DIVERSITY Theoretical considerations would lead to the expectation that schizoid PD is far more frequent in men than in women. Current theory indicates that men are less related than women. Levant (1995) discussed "normative male alexithymia" to indicate the frequent observation that men lack words for feelings. Although we might expect high ratios of men relative to women, as in narcissistic or antisocial PDs, current prevalence data do not indicate these differences. According to the DSM-IV-TR, there are "slightly" more men than women with schizoid PD, and they appear to be more severely impacted by it (American Psychiatric Association, ZOOOa). Perhaps, then, passivity is more acceptable and less damaging to the feminine role than to the masculine. A man who is passive, noncompetitive, and underachieving may be deemed more unacceptable, given American culture's emphasis on male dominance and achievement. American culture may be more tolerant of passivity in women. Even within the female role, however, a woman with schizoid PD may experience pressure for not being sufficiently nurturing, assuming that she dates, marries, or has children; this issue is addressed in the case study below. 82

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Low socioeconomic status is generally a risk factor for psychopathology (Dohrenwend & Dohrenwend, 1969). There is a well-known association between schizophrenia and low socioeconomic status (Eaton & Harrison, 2001), which likely generalizes, at least to some degree, to the schizophrenia spectrum. The two main theories of the etiological impact of low socioeconomic status are social causation (e.g., that poverty increases stress levels, causing psychopathology) and social selection (i.e., that psychopathology impairs productivity and leads to poverty; Dohrenwend et al., 1992). In general, both factors work simultaneously (Johnson, Cohen, Dohrenwend, Link, & Brook, 1999). For example, an impoverished individual may become depressed in part because of his poverty. Because he is unable to afford treatment, his depression worsens, and he loses his job, leading to increased poverty. It should be noted that in some cultures, what DSM-IV-TR labeled "schizoid" is considered the highest state of being. The Buddhist monk (Foulks, 1996, p. 249) or Hindu yogi (Castillo, 1997) yearn to experience a state of inner emptiness, freedom from striving, a focus on the present, and a lack of "ego" (in the sense of individual identity and the pride that goes with it), and to be free from emotions and attachments. Such individuals engage in regular meditation practice to attain such a state. I doubt that many clinicians would confuse the practiced, refined state of tranquility of the Buddhist or Hindu cleric with the inner deadness of the depressed person with schizoid PD. However, members of the Buddhist and Hindu religions may accept or even value ways of being that a practitioner from a Western perspective may see as problematic. In addition, Castillo (1997) noted that an individual is more likely to be labeled schizoid if he or she has a "stigmatized moral career": There are a number of ways that a person with a stigmatized moral career can adapt to the social environment, thus structuring personality development. For example, stigmatized persons can accept their status and "act accordingly," that is, passively accept their low status. These persons will likely have low self-esteem. They accept society's definition of them as being inferior, flawed, incapable, unworthy, inadequate, unacceptable, and so on. They internalize this stigmatized view of themselves, literally structuring it into the neural networks of their brains. These neural networks then structure their cognition of the world, (p. 42) One can easily see the origins of depression in this conceptualization. Low self-esteem and beliefs that one is inadequate are part of the diagnostic criteria for major depression and dysthymic disorder. The passivity of the individual with schizoid traits makes this "accepting" adaptation likely. As implied in the analysis above, both depression and schizoid personality disorder would be more likely to develop in hierarchical societies such as the United States (Castillo, 1997, p. 100). Some cultures have more muted forms of expression than others. For example, individuals from Scandinavian cultures tend to be more reserved than SCHIZOID PERSONALITY DISORDER

83

people in the United States. Thus Scandinavian families may have a greater tolerance for the reduced emotionality associated with schizoid PD. However, Scandinavians are as sociable as Americans, and the withdrawal of the individual from family and community life would be seen as problematic. Conversely, families from highly expressive cultures (e.g., Hispanic) may have a great deal of difficulty with the schizoid individual's lack of warmth and emotionality, and the schizoid behaviors may be particularly troubling to the family. DSM-IV-TR cautioned that there are several groups that may be erroneously labeled schizoid. Individuals who move from rural to urban areas may exhibit "emotional freezing" (American Psychiatric Association, ZOOOa, p. 695) for up to several months. Similarly, immigrants may be misperceived as cold or indifferent.

STRENGTHS OF PERSONS WITH SCHIZOID PERSONALITY DISORDER When one considers the person-environment match, it is not difficult to see that there are many aspects of schizoid PD that are adaptive to certain conditions. Individuals with a low need for stimulation do well at repetitive tasks or isolated jobs that would mercilessly bore most people. Institutionalized clients with restless temperaments grow agitated and desperate; the person with schizoid features adapts extraordinarily well to institutional life. Although living in an institution may not be considered ideal, for individuals with certain kinds of problems it is the setting in which they will spend a great deal of their time. It is a sad reality that the needs of institutions to provide minimal staff-patient contact and to have maximal patient compliance with routines that are generally rather dull favors features of schizoid, dependent, and obsessive-compulsive personality disorders. There are also personality strengths inherent in schizoidal features that fall within the "normal" or positive range of functioning. Being eventempered, steady, and calm are traits that stand one in good stead in many situations. A person with schizoid PD who improves in psychotherapy can be expected to retain these positive characteristics. As noted previously, advanced meditators achieve a state of inner peace through disciplined practice, attaining a state that bears some resemblance to the person with schizoid PD's natural way of being; the client could capitalize on that proclivity in therapy.

TREATMENT PLANNING: SYNERGISTIC TREATMENT Personality-guided therapy (PGT) treatment goals flow logically from the conceptualization of the client, per Millon's theory. Because the person 84

PERSONAL1TY-G UIDED THERAPY FOR DEPRESSION

EXHIBIT 4.2 Therapeutic Strategies and Tactics for the Prototypal Schizoid Personality STRATEGIC GOALS Balance Polarities Increase pleasure/enhancing polarity Increase active/modifying polarity Counter Perpetuations Overcome impassive behaviors Increase perceptual awareness Stimulate social activity TACTICAL MODALITIES Energize apathetic mood Develop interpersonal involvement Alter impoverished cognitions. Note. From Personality-Guided Therapy (p. 291), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

with schizoid PD is considered the passive-detached type, naturally, the goal is to balance the polarities by helping the client to become more active and more attached to others. Because the person is pleasure deficient, an additional goal is to increase pleasure. It is also important to undercut processes that tend to perpetuate the schizoid pattern. Vicious circles of the person with schizoid PD include (a) extreme passivity, which undermines the development of assertiveness and other appropriate skills; (b) lack of social awareness, which leads to unpleasant social interactions, thus further reducing opportunities to perceive social cues; and (c) the tendency to withdraw, which generally leads to further withdrawal. Thus, therapy should be geared toward reducing impassive behaviors, improving social awareness, and increasing social activity (see Exhibit 4.2). The long-term goals for depressed individuals with schizoid PD include increasing their activity level, enhancing pleasure, improving their social interactions and increasing their frequency, and bringing clarity to their vague cognitions so they can recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma & Peterson, 1999). For the client with schizoid PD and depression, motivation will often be problematic; thus, the best initial interventions will be those that offer the best hope of rapid change. Behaviorally lethargic, people who have both depression and schizoid PD typically first respond best to cognitive interventions; they can challenge their negative thoughts and improve their mood while expending minimal physical energy. If the depression is not so severe that it precludes psychotherapeutic improvement, then it is best to wait for some psychological improvements to occur before introducing psychopharSCHIZOID PERSONALITY DISORDER

85

macological interventions; the typical person with schizoid PD, who is not very psychologically minded, may be prone to attributing any gains made to medications and lose motivation to make psychological changes. Behavioral techniques could then be added, targeting specific social skills to improve (e.g., assertiveness), or specific antidepressive behaviors (e.g., exercise or reengaging in a favored hobby). Establishing these fundamental skills will generally be very helpful prior to attempting to repair the deeper interpersonal and structural problems the person encounters. Cognitive improvements, such as changing self-defeating thoughts, and adding skills, such as increased assertiveness, are likely to have positive interpersonal consequences. For example, the depressed person with schizoid PD may have the thought, "I am so worthless that no one would want to be with me," which may lead to neglecting a relationship ("It's just going to end anyway")- If these beliefs have been corrected with cognitive therapy, then the individual is likely to be more receptive to discussing relationship issues. Interpersonal interventions, then, can build on cognitive improvements, strengthening the person's relationships. Group and family interventions can either run concurrently with, or replace, individual treatment. As mentioned previously, group interventions have the distinct advantage of allowing the individual to practice social skills with peers. Family interventions can have positive motivational aspects as well because the therapist can provide support for beleaguered family members while supporting the client, and the family can help motivate the client to continue to come to treatment. Depth approaches, such as psychodynamic interventions, would generally be considered last because they tend to produce change more slowly and thus require greater motivation on the part of the client. The current therapist can implement psychodynamic interventions, though in some cases it would be wise to refer the client, thus allowing the transference to form anew.

CASE EXAMPLE: CANDACE AND LORENZO It is not a coincidence that most of the clients whom I saw who had schizoid PD also had histories of major psychopathology (e.g., schizophrenia or bipolar disorder). I saw them mostly when I was an intern working for the New York state psychiatric system. Their schizoid PD was never the reason that they saw themselves coming for therapy. However, in the case below, the severe Axis I psychopathology had been stabilized, leaving some Axis I depression and anxiety, and the underlying schizoid PD, as treatment issues. At the time I met her, Candace, a 42-year-old divorced White AngloSaxon Protestant woman, had had a long history of depression and schizophrenia. She had been hospitalized for schizophrenia on several occasions, but when I started seeing her as an outpatient, she was stable on medications and had not been in the hospital for a number of years. I saw her for approxi86

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

mately 1 year, and she was not psychotic during that time. Candace's schizophrenia was treated with low-dose neuroleptics, and she had chronic anxiety, for which she took buspirone. She had chronic, vague feelings of sadness, which, when combined with her passivity, would meet the criteria for dysthymic disorder. Candace also met the criteria for schizoid PD. Although an intelligent woman—she had received a college education and worked as an editor—her descriptions of her relationships were quite impoverished. She had a 22-yearold daughter who was in college and whom she saw occasionally. When she would mention her daughter or say that her daughter was coming for a visit, she evinced neither excitement nor displeasure. This was her closest family relationship; she rarely mentioned her parents or other family members. Unlike most depressions, Candace's appeared to lack substantial interpersonal components. She did not describe being depressed because she felt unloved or unlovable, unwanted, or abandoned. She stated that she felt empty at times, and she also described feeling different from others. She had a history of suicidal ideation when she was in the psychiatric hospital suffering from schizophrenic symptoms. Her frightening delusions and hallucinations led her to feel hopeless that she would ever get out of the hospital or recover. Once she stopped having hallucinations, she stopped having suicidal ideation. The presenting problems at the time of referral were relationship difficulties between Candace and her boyfriend, Lorenzo. As is common in internship settings, I "inherited" the case from a prior intern, and Candace and Lorenzo were already in ongoing couples therapy; I continued, then, to see them as a couple. However, I was not insistent on seeing both members of the couple at once (Napier, 1978); if one person was sick and the other still came, I would see just that person. During those occasional individual sessions, we would refrain from talking about couple issues but rather would work on individual issues. With Candace, one of our better sessions on her depression occurred during one such session. Lorenzo was diagnosed with borderline intellectual functioning. His personality style was dramatic, and although he did not have a diagnosable personality disorder, he had features that were primarily histrionic and somewhat dependent. Lorenzo wanted much more from the relationship with Candace—marriage, as well as increased closeness and intimacy. Candace was satisfied with how things were and seemed a bit puzzled by Lorenzo's needs and desires. Thus there was a striking reversal of common American gender patterns in this case. Candace was the breadwinner, unemotional, and relatively alexithymic; Lorenzo, on the other hand, was more emotion focused and demonstrative. Candace came from a family that was formal in its structure. Dinner was eaten together at the same time each day, accompanied by polite, quiet conversation. Children were expected to be "seen and not heard." Achieve SCHIZOJD PERSONALITY DISORDER

87

ment and education were emphasized. She stated that her parents cared most about her grades and that because she always did well in that area, her parents "didn't hassle her." Her meager social life was accepted as being "her decision." Lorenzo's Hispanic family was more demonstrative, openly displaying warmth and affection. There was no abuse in either family, although Lorenzo endured a moderate amount of teasing as a child. The manner in which Candace and Lorenzo were raised was consistent with their White Anglo'Saxon Protestant and Hispanic subcultures, respectively (Garcia-Preto, 1996; McGill & Pearce, 1996). However, although Lorenzo's histrionic and dependent features may have been normative within the context of an expressive, tightly knit Hispanic family, Candace's social withdrawal and aloofness were clearly beyond what would be considered appropriate within her culture. Candace's strengths included a general kindness—although not particularly empathic, she did try to be helpful to others, and she was never malicious. She was both consistent and patient with Lorenzo. She was bright, hardworking, and confident in her abilities as an editor. Though she was not warm or demonstrative, she took pride in her daughter's accomplishments and provided for the daughter's material needs. She coped very competently with her schizophrenia; she had excellent insight and was fully compliant with her medication regimen. It was interesting that the vast difference between Candace's and Lorenzo's IQs never became an issue. This was most likely because of Candace's nonstriving and "egoless" nature; she did not have a need for status that would have required her boyfriend to be highly accomplished. Candace also tended to express herself in a simple and straightforward fashion, and so Lorenzo had no difficulty understanding her. Lorenzo also demonstrated a variety of strengths. A warm and caring individual, he was able to be consistently affectionate with Candace. Without his persistence—or, put differently, if Candace were dating someone with a personality more similar to her own—the relationship likely would have drifted into isolation and separateness. Lorenzo was also able to take advantage of the programs offered through state and community facilities that provided him with work, activities, and independence. Candace was not completely detached. She preferred to have some company some of the time. She enjoyed spending time with Lorenzo but did not want him to move in and did not want to increase the amount of time they spent together (they would meet several times per week). In addition, therapy provided Candace with some measure of support that she seemed to appreciate. Treatment initially consisted primarily of cognitive interventions. Candace had beliefs such as "I am empty" and "I am odd and different" that led to feelings of depression. She was encouraged to challenge these beliefs and came up on her own with the notion that each person is unique, and who is to say what is acceptable or not? Unconditional positive regard on the part 88

PERSONAL/TY-G UIDED THERAPY FOR DEPRESSION

of the therapist arid Lorenzo's persistent affection were consistent reminders that she was an acceptable person. As for the belief that she was empty, her emotional reasoning (I feel empty, therefore I am empty) and her dichotO' mous reasoning ("I am empty" as opposed to "At times I feel empty") were challenged through Socratic dialogue. Over time, her belief was modified to "At times I feel empty, but I often feel fulfilled as a mother to my daughter, a girlfriend to Lorenzo, and in my job." Lorenzo had beliefs such as "Candace does not really love me or she would marry me"; "If we do not get married, that is terrible"; and "Candace must be more affectionate with me, or I cannot bear it." These beliefs were challenged against his experience and, gradually, were reframed as preferences, for example, "I would prefer it if Candace were more affectionate." The belief that Candace would marry him if she loved him was challenged, on the basis that Lorenzo would lose valuable disability benefits if the couple got married. Although marriage was highly preferable to Lorenzo, particularly given his religious upbringing, he was able to see that Candace's finances were stretched to the limit in supporting her daughter through college. After the most distressing beliefs were effectively challenged, the treatment approach shifted to become more interpersonally focused. During this phase of treatment, Lorenzo more frequently raised issues that were distressing to him. On a number of occasions, he would protest that unless Candace could be more affectionate, then perhaps they should break up. Candace was not ruffled by these threats, which did not seem to be particularly genuine. However, at least one form of affection could be improved. Sexual counseling with the couple enabled them to experience more warmth and intimacy. At that point, it became clear that Candace had reached the limits of her motivation, and probably her ability, to become warmer and more demonstrative. Although the words "schizoid personality disorder" were never used, the concept of "this is just how she is" was used as a way of discussing personality variables. As a way of helping Lorenzo to empathize, I noted that just as it was difficult for Lorenzo to reduce his desires, it was difficult for Candace to increase hers. Ultimately, it came down to a choice—"Can you accept her for who she is? Can you accept him for who he is?" They continued to stay together, and though ambivalent at times, they were more flexible, accepting, and realistic about both themselves and each other. The overall tone of the relationship had become warmer and more affectionate. Candace was less depressed, and Lorenzo was less angry and anxious. They recognized each other's strengths—that she was drawn to his emotionality and enjoyed his devotion to her, and he appreciated her patience and consistency. Although 1 did not then work with psychodynamic concepts in this case—for example by looking at unconscious motivations, early family relations, repetitions of prior patterns, and compensatory strivings—PGT prinSCHIZOID PERSONALITY DISORDER

89

ciples indicate that such an approach would have been an appropriate step. Dynamically oriented therapy may have helped the couple gain further insights and enable them to achieve a better understanding of both the self and the other person (e.g., Ackerman, 1958). If it were not possible to switch from the current supportive mode to psychodynamic therapy—a real possibility, because the transference has already been shaped by supportive interventions—then an alternative would have been to add a psychodynamically oriented individual therapist for one or both members of the couple. I continued to see the couple throughout the remainder of the year, although the gains described above were mostly accomplished during the first 8 months. Given the numerous challenges that they faced—schizophrenia, depression, and borderline intellectual functioning—long-term supportive therapy was used for relapse prevention and to prevent hospitalization. After I terminated with the couple, they were transferred to a new intern.

SUMMARY AND CONCLUSIONS Schizoid PD with depression can be difficult to treat because of low energy levels and motivation. With realistic expectations regarding recovery, prognosis is reasonably good. As illustrated by the case of Candace and Lorenzo, a series of synergistic sequences led to significant improvements. Establishing trust was not particularly difficult. Cognitive techniques (challenging distorted thoughts such as Lorenzo's experiencing Candace's reserve as personal rejection) and interpersonal-family techniques (e.g., sexual counseling) led to improvements in the couple's relationship as well as decreased symptoms in each individual. For purposes of PGT for depression, empirical research on catalytic sequences, beginning with examining potential motivational strategies, would be appropriate. Research on medications may be more important with this population than with others, because motivation for change is a key ingredient for success in psychotherapy, and the lethargy that typifies individuals with schizoid PD and depression needs to be countered.

90

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

5 DEPRESSION IN SCHIZOTYPAL PERSONALITY DISORDER

The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) described schizotypal personality disorder (PD) as "a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior" (p. 697). Individuals with schizotypal PD are seen by others as eccentric, odd, or just plain weird. They have strange, loosely connected thoughts, superstitions, and, frequently, paranoia. They may believe that they have special powers, especially clairvoyance or extrasensory perception.

PHENOMENOLOGY: THE EXPERIENCE OF SCHIZOTYPAL PERSONALITY DISORDER Interpersonally, individuals with schizotypal PD are generally withdrawn. However, the social withdrawal can occur for different reasons. People with schizotypal PD can be thought of as belonging to one of two subtypes, as

91

noted by Millon (1996, 1999)—a schizotypal-avoidant type (Millon's timorous schizotypal) and a schizotypal-schizoid type (the insipid schizotypal). The timorous schizotypal individual longs to be accepted but, fearful of rejection, actively avoids others. More dysfunctional than most avoidant persons because of the additional challenge of cognitive slippage, persons belonging to this subtype have likely experienced excessive actual rejection, especially in the form of teasing as a child. Like other avoidant people, they are highly prone to depressive and anxiety disorders. The insipid schizotypal person has a generally more comfortable time of it than the timorous type; for this individual, passive and detached, rejection by others does not wound. As with other schizoid persons, however, this can lead to a lack of motivation to change and a continued pattern of poor adjustment and underachievement. Individuals with schizotypal PD as well as depression, then, are more likely to be of the timorous sort—anxious, fearful, wanting connection with others but unable to attain it, and thus always feeling as if they are "on the outside looking in." Of course, social withdrawal is also associated with depression alone, so a person with either subtype of schizotypal PD with comorbid depression is likely to be quite withdrawn. The depressive thoughts are also often moderated, if you will, by the person's cognitive dysfunction. For example, in the case example at the end of the chapter, the client presented with quasi-delusional thoughts (e.g., Demons are stealing my clothing) rather than a more direct expression of dysphoric affect (e.g., "I feel helpless and vulnerable").

EPIDEMIOLOGY The prevalence of schizotypal PD, according to DSM-IV-TR, is 3.0% in the general population. According to a meta-analysis of nine communitybased studies by Mattia and Zimmerman (2001), the prevalence of schizotypal PD is 1.8%. At least one study (Maier, Lichtermann, Klingler, Heun, 6k Hallmayer, 1992) noted that schizotypal PD was diagnosed more frequently in men, although that hypothesis was not statistically tested. Approximately one half of individuals with schizotypal PD have a history of major depression (American Psychiatric Association, 2000a; Siever, 1992). Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 12.9% had schizotypal PD. In Pepper et al.'s (1995) dysthymic disorder sample, 4% had schizotypal PD. In another sample of depressed clients, approximately 3% had schizotypal PD (Fava et al., 1995). In a sample of 249 depressed outpatients, fewer than 1% were diagnosed with "definite," and 1% with "probable," schizotypal PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). Among individuals with major depression, 65.2% met the criteria for schizotypal PD. In a sample of 352 clients with both anxiety and depression, approximately 2.3% had schizotypal PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 92

PERSONAUTY-G UIDED THERAPY FOR DEPRESSION

1993). The range, then, is virtually none (fewer than 1%) to nearly two thirds (66.3%) of individuals with depression having schizotypal PD. Likely reasons for the enormous range include natural sample variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria—for example, some studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), and some used criteria from the revised third edition (DSM-III-R; American Psychiatric Association, 1987). Further research clarifying the overlap of depression and schizotypal PD is warranted. There are fewer data on the prevalence of depression in a sample of individuals with PDs, although the findings are more consistent. Zimmerman and Coryell (1989) studied a community sample of 797 individuals, which included 143 individuals who were diagnosed with personality disorders. Among those with schizotypal PD, 65.2% met the criteria for major depression. A study that included 86 clients with schizotypal PD found that 66.3% had major depression (McGlashin et al., 2000). WHY DO PEOPLE WITH SCHIZOTYPAL PERSONALITY DISORDER GET DEPRESSED? Depression in people with schizotypal PD is likely to be precipitated by major cognitive problems associated with the personality disorder. The person with schizotypal PD is highly prone to feelings of depersonalization. As stated by Millon (1981), The deficient or disharmonious affect of schizotypals deprives them of the capacity to experience events as something other than flat and lifeless phenomena. They suffer a sense of vapidness in a world of cold and washed-out objects. Moreover, schizotypals feel themselves to be more dead than alive, insubstantial, foreign, and disembodied. As existential phenomenologists might put it, they are threatened by "nonbeing." (p. 413)

Anyone who persistently experienced such thoughts and feelings would likely experience depression and anxiety. Schizotypal PD and major depression with psychotic features can interact with negative synergy. As illustrated in the case study below, a woman whose clothing was being stolen or misplaced in a nursing home developed the delusion that demons were stealing her clothing. Her depression, which was in part related to the loss of control, stimulation, and freedom associated with living in a nursing home, rapidly deteriorated from an adjustment disorder to a major depression with psychotic features. Conversely, paranoid ideation can also be depressing. Although anger and self-righteous indignation can sometimes help the person with paranoid personality disorder to ward off depression, such is rarely SCHIZOTYPAL PERSONALITY DISORDER

93

the case with the person who has schizotypal PD, who is likely to simply feel vulnerable, overwhelmed, and frightened. Although social withdrawal is pervasive among people with schizotypal PD, an excess of detachment is depressing. Most of us, even the more sociable among us, have experienced a desire for privacy after a period of intensive social interaction or a desire to "get out there" after a period of reclusiveness; similarly, the person with schizotypal PD has a threshold that produces discomfort when exceeded. For most people with schizotypal PD, considerable anxiety accompanies an amount of social interaction that most people would consider normal or even sparse, whereas depression is likely to ensue when isolation becomes excessive. Minnesota Multiphasic Personality Inventory Scale 8, Schizophrenia, contains a substantial number of items that essentially measure social alienation. As in schizophrenia, social alienation is a major component of schizotypal PD. People with schizotypal PD were often odd or different from an early age and experienced substantial peer rejection as children. This feeling of being odd, different, or an outcast is often depressing and can lead to depression later in life. Social disengagement itself can predispose one to a generally poor adjustment and put one at risk for a variety of disorders, including depression. As noted by P. Kernberg, Weiner, and Bardenstein (2000), Teacher reports from the beginning of the Danish High-Risk Study (Olin et al., 1997) confirm that children later diagnosed with [schizotypal PD] were seen as passive and socially unengaged, hypersensitive to criticism, and nervously reactive to events; they did not show social anxiety until adulthood. This research suggests that social anxiety develops as a consequence of the passivity and hypersensitivity that reduces children's socializing opportunities. Their particular traits may also render them ill-prepared to acquire behaviors for mastering the challenges of adulthood for sexuality, intimacy, job, and autonomy and separation, (p. 231) Consistent with the "vulnerability" model of the relationship between Axis I and Axis II, there are several ways in which schizotypal PD appears to make the person more susceptible to depression when under stress (see chap. 2). In addition, to the extent that depression leads to further withdrawal and isolation, the two disorders intensify one another, consistent with the "exacerbation" model. The first of Millon's two subtypes of schizotypal PD, the insipid type, is mainly a mixture of schizotypal and schizoid features. In such cases, the person has extremely limited emotions and thus would be less prone to depression. The second type, the timorous type, is primarily a mixture of schizotypal and avoidant features. Such individuals present as touchy, overstimulated, and hypersensitive. They are prone to anxiety and depressive disorders. For the person with avoidant features, there is usually a strong desire to be ac94

PERSONALITY^ U1DED THERAPY FOR DEPRESSION

cepted by others and profound feelings of humiliation and rejection. For the individual who also has schizotypal features, this feeling of oddness, differentness, and rejection was typically reified through early experiences of persistent peer rejection. Often difficulties in clear and rational thinking and the tendency to slip into quasi-delusional and paranoid states only exacerbate depressive feelings and complicate treatment. HOW A PERSON BECOMES AND REMAINS SCHIZOTYPAL: THEORIES OF SCHIZOTYPAL PERSONALITY DISORDER Biological Factors Schizotypal PD shares with schizophrenia symptoms of oddness, eccentricity, and cognitive slippage. Meehl (1962, 1990) labeled this underlying dimension schizotaxia. Meehl's 1962 hypothesis that schizotaxia has a substantial genetic component has been supported by a variety of studies. Studies have also shown that schizotypal PD is biologically related to schizophrenia, thus justifying the conceptualization of schizotypal PD as part of the "schizophrenia spectrum" disorders (Siever, 1992). A number of studies have shown that schizotypal PD is at least moderately heritable. Genetic factors accounted for approximately 50% of the variance in dimensional measures such as social avoidance (Livesley, Jang, Jackson, &. Vernon, 1993), restricted expression, and inhibition and for 38% of the variance in affect constriction (for a review, see Jang & Vernon, 2001). Family studies have shown an increased rate of schizotypal PD (or its symptoms) in biological relatives of schizophrenics (vs. adoptive relatives), and, conversely, the rate of schizophrenia in relatives of individuals with schizotypal PD is higher than in the general population (for a review, see Tyrka et al., 1995). According to a review by Siever et al. (1998), studies have shown that individuals with schizotypal PD have a variety of cognitive dysfunctions that are similar to those of individuals with schizophrenia but lower in severity. Executive function, visuospatial working memory, verbal memory, and sustained attention are all impaired. Studies have shown that similar to individuals with schizophrenia, people with schizotypal PD have an excess of dopamine (Siever et al., 1991). Fukuzako, Kodama, and Fukuzako (2002) found phospholipid abnormalities in the left temporal lobe. A magnetic resonant imaging (MRI) and positron-emission tomography study demonstrated that a schizotypal PD group was in between a schizophrenic group and a normal control group in metabolic rates in the prefrontal area while performing a verbal learning task (Buchsbaum et al., 2002). Neuroanatomical Features

Like individuals with schizophrenia (though to a lesser degree), individuals with schizotypal PD have increased ventricular volume and asymmeSCHIZOTYPAL PERSONALITY DISORDER

95

try relative to normal controls (Buchsbaum et al., 1997), research participants with other personality disorders (Siever et al., 1995), and research participants with a variety of non-schizophrenia-spectrum disorders (T. D. Cannon et al., 1994). Neuroanatomical differences include substantial (21%) decreased left Heschl's gyrus volume (Dickey et al., 2002), which is related to problems with logical memory. Similar to medication-naive schizophrenic subjects, a sample of individuals with schizotypal PD had reduced caudate nucleus size relative to matched non—psychiatrically disordered controls; reduced caudate nucleus size is related to problems in working memory (Levitt et al., 2002). An MRI study showed that temporal lobe size is smaller in individuals with schizotypal PD than in normal controls (Downhill et al., 2001); the authors interpreted their findings to indicate that gray matter loss in the temporal lobes, with intact white matter connectivity, relates to the psychopathological symptoms of schizotypal PD. The corpus callosum of schizotypal PD samples had reduced volume and a different shape from those of normal controls, suggesting reduced connectivity in the brains of individuals with schizotypal PD (Downhill et al., 2000). There is evidence that there are prenatal neurodevelopmental abnormalities, based on the discovery of minor physical anomalies that are known to originate prenatally, studied cross-sectionally in a group of schizotypal research participants relative to a nondisordered comparison group (Weinstein, Diforio, Schiffman, Walker, & Bonsall, 1999) and longitudinally in a schizotypal PD sample (E. F. Walker, Logan, & Walder, 1999). Using MRI and positron-emission tomography scans, Shihabuddin et al. (2001) showed that a sample of participants with schizotypal PD had reduced volume and increased metabolism of the putamen relative to both schizophrenic and control participants. According to the authors, "These alterations in volume and activity may be related to the sparing of patients with [schizotypal PD] from frank psychosis" (p. 877). A reasonable summary of the biological literature is that schizotypal PD is similar to schizophrenia but milder in degree. Medications Preliminary evidence has suggested that several dimensions of schizotypal PD can be addressed with medications. Schulz, Schulz, and Wilson (1988) provided a review of medications for schizotypal PD, including some older studies of pseudoneurotic schizophrenia (a forerunner of schizotypal PD). The authors reviewed three studies that contained pseudoneurotic schizophrenia samples: The study by Klein (cited in Schulz et al., 1988) was doubleblind and placebo controlled; the study by Hedberg, Houck, and Glueck (cited in Schulz et al., 1988) was double-blind but not placebo controlled; and the study by Aono et al. (cited in Schulz et al., 1988) was an open trial. As expected, neuroleptics decreased psychotic-like symptoms; surprisingly, they helped with depression as well. Also surprisingly, the effects of antidepressants were not limited to affective symptoms; indeed, in one study, the 96

PERSONALITY-Gl/IDED THERAPY FOR DEPRESSION

monoamine oxidase inhibitor tranylcypromine was more efficacious than triflurophenazine in reducing overall symptoms (Hedberg et al., cited in Schulz et al., 1988); in another study, imipramine reduced symptoms more than chlorpromazine (Klein, cited in Schulz et al., 1988). The Aono et al. (cited in Schulz et al., 1988) study demonstrated that the antidepressant amoxapine seemed to be effective for both psychotic and neurotic symptoms. Schulz et al. (1988) reviewed four later studies that examined the effects of neuroleptic medication prescribed in low doses, as well as antidepressant medications in their usual therapeutic dosage. Unfortunately for our present purposes, most of the samples were a mixture of individuals with borderline PD and schizotypal PD. The studies were modest in size (17-52 participants) but were either double-blind or single blind. The four studies taken together support the low-dose neuroleptic strategy, with at least one study demonstrating similar improvements in participants regardless of diagnosis (e.g., borderline PD, schizotypal PD, or both). Neuroleptics generally outperformed tricyclic antidepressants (which had equivocal results and made some participants considerably worse). Later studies defined schizotypal PD participants more precisely and used newer medications. Preliminary findings with atypical antipsychotics are encouraging. Scarciglia, Gherardelli, Tarsitani, and Biondi (2004) presented a case study that demonstrated a reduction in dissociative episodes using olanzapine. Keshavan, Shad, Soloff, and Schooler (2004) performed a 26-week open-label trial of olanzapine with 11 participants; they found significant improvements in psychosis, depression, and overall functioning. Koenigsberg et al. (2003) performed a 9-week randomized clinical trial of risperidone with 25 participants. As assessed by the Positive and Negative Syndrome Scale, negative schizophrenic symptoms began to remit by Week 3, and a reduction in positive symptoms had occurred by Week 7. Newer antidepressants may also be helpful. One study has shown that depressive symptoms remit with fluoxetine treatment (Markovitz, Calabrese, Schulz, &. Meltzer, 1991); however, these results should be interpreted with caution because the study was uncontrolled, and the small sample (N = 22) was a mixture of individuals with borderline and schizotypal PDs. Jensen and Anderson (1989) found in their 39-day open-label trial that the tricyclic antidepressant amoxapine helped to reduce schizophrenia-like and depressive symptoms in the five schizotypal PD participants in their sample. It is not clear if amoxapine is superior to imipramine in treating schizotypal PD symptoms, if the high percentage of borderline PD individuals in the Soloff et al. (1986) study led to different results, or if Jensen and Andersen's (1989) miniscule sample (N = 5) was too small to detect iatrogenic effects. In all, the evidence above supports, albeit tentatively, Joseph's (1997) concise conclusion: Strictly from a symptomatic approach, schizotypal personality disorder can be considered a mild form of schizophrenia with the same characterSCH/ZOTYPAL PERSONALITY DISORDER

97

istics except that psychotic thought, perceptual, and affective symptoms are mild; hence the personal, social, and occupational deterioration are proportionately less severe. . . . Since the difference is quantitative and not qualitative, the treatment employs similar medications, the primary difference being in the dose size. (pp. 58-59) Joseph (1997) provided a case illustration of a 50-year-old woman who had schizotypal PD and depressed mood. Her symptoms included poor memory, poor concentration, ideas of reference, obsessive ruminations, and insomnia. She was treated with fluoxetine, risperidone, temazepam, and psychotherapy. Noted Joseph, "The patient reported almost complete resolution of most symptoms, and felt that she should have started this treatment 25 years ago" (p. 62). Psychological Factors In the biopsychosocial model, the psychological level falls between the highly individual biological level and the large-scale sociocultural level. Psychological factors include the person's learned behaviors, beliefs, emotions, unconscious strivings, and interpersonal relationships. Several established lines of thought emphasize different aspects of the person's experience, and will be described in turn below. Millon's Theory Millon conceptualized schizotypal PD as a more severe, "decompensated" variant of the schizoid or avoidant PDs. Thus, in terms of Millon's tripolar theory, the person with schizotypal PD may appear to be passively detached or actively detached. In contrast to the less severe counterparts of the disorder, people with schizotypal PD also have instabilities on the painpleasure dimension. Where the person with schizoid PD has a deficiency in both pain and pleasure and the person with avoidant PD has an excess of pain sensitivity, the individual with schizotypal PD has weakness along the pain-pleasure dimension such that the two poles may reverse (pleasure is experienced as painful). As Millon (1999) stated, In essence, this signifies that none of the survival motives and aims of the schizotypal have a firm grounding. Rather, they are feeble in their intensity and focus, and can be easily reversed or distorted in their usual objectives and goals. The figure portrays their rather ineffectual existence, as well as the meaningless and eccentric character of their activities. Possessing little spark or drive, these individuals become increasingly estranged from social conventions, (p. 617) Thus, persons with schizotypal PD tend to drift in a downward spiral. Their social withdrawal leads to insufficient stimulation, lack of checks and balances on quasi-delusional thinking, and thus further autistic reasoning 98

PERSONALITY-G V1DED THERAPY FOR DEPRESSION

and social inadequacy. When life forces them to interact with others for survival, they easily become overwhelmed, to which they typically respond by "blanking out" or with a burst of poorly modulated aggression. At times, they become frankly psychotic. Any of these reactions furthers their social alienation and decreases the probability of stable, positive structures in their daily lives. The description of the person with schizotypal PD in terms of Millon's domains is presented in Appendix B. Of the features listed, cognitive disturbance and social withdrawal are the most prominent. Cognitive-Behavioral Conceptualization and Interventions Cognitive—behavioral therapists note the elevated importance of a sound therapeutic relationship with the person with schizotypal PD. Their proclivity to paranoid thinking and difficulties with social interactions can easily sweep away the therapeutic relationship early in treatment. Only after a therapeutic bond is established, through copious active listening and clearly understanding the client's point of view, can cognitive-behavioral therapy (CBT) technically begin. A recent and rapidly growing area in the cognitive-behavioral literature is the treatment of psychotic disorders using CBT. At this point, studies have debunked—or at least refined—the old saying that "you can't talk people out of their delusions." CBT has been effective in decreasing the frequency of delusions and the firmness of conviction with which they are held (Haddock et al., 1998; Kingdon & Turkington, 1994). The technique for doing so is to challenge a delusion just like any other belief, especially using thought records and Socratic dialogue. So although "you can't talk a man out of his delusions," one might say that you can show him how to talk himself out of them. Behavioral experiments, carefully structured so that they can provide evidence for or against a belief, are an integral and essential part of the treatment. In retrospect, much treatment for depression is similar. The belief of the bright but depressed college student that she is "stupid" is similar to a nonbizarre delusional belief. Thus methods that are used with quasidelusional and delusional beliefs will pave the ground for treating depressive ideation, and vice versa. Accustomed to trusting their feelings and intuitions, clients with schizotypal PD need to learn to evaluate evidence. Common thoughts experienced by people with schizotypal PD include believing they are dead, believing that they or someone else is possessed by the devil or evil spirits, and paranoid thoughts such as "1 cannot trust my mother." Instructing the client to gather the appropriate evidence and evaluating that evidence during the session can challenge such thoughts. A. T. Beck, Freeman, and Davis (2004) noted that common core beliefs among individuals with schizotypal PD include "I am different and abSCHJZOTYPAL PERSONALfTY DISORDER

99

normal" and paranoid ideas such as "people are cruel." They may have ambivalence about these beliefs, on the one hand recognizing that they are a source of distress but on the other hand thinking that their beliefs keep them safe. Working through this ambivalence with a cost-benefit analysis and behavioral experiments can help the individual to make informed choices regarding behavior change. Client-Centered, Humanistic, and Existential Therapies

Client-centered therapy would be a natural fit for someone with schizotypal PD and depression. Feelings of alienation are likely to be prominent, and a consistent, empathic approach is a powerful remedy for such feelings. Existential therapy may also be extremely useful for depressed clients with schizotypal PD. As they grapple with feelings of emptiness and meaninglessness, a therapy that specifically addresses purpose in life could be a powerful antidote (Frankl, 1983; May, 1983b). For the clinician who is not specifically existentially oriented, assigning the client a book to read such as Don't Sweat the Small Stuff (Carlson, 1997), The Miracle ofMindfulness (Nhat Hanh, 1976), or Wherever You Go, There You Are (Kabat-Zinn, 1994) is a useful starting point. Simply assigning the client to read a few pages and then asking if there was anything that he or she found meaningful can lead into a productive discussion of how to find or create meaning in one's life. Psychodynamic Therapy

From the standpoint of psychodynamic theory, schizotypal PD is a somewhat more severe manifestation of schizoid personality phenomena. Please see chapter 6, this volume, for further discussion. Family Systems There is little if any literature on the family treatment of individuals with schizotypal PD. However, a variety of family interventions have been helpful for people with schizophrenia; many aspects of such treatments apply directly to schizotypal PD, and others can be used with minimal modification. Behavioral family therapy (BFT; see studies by C. M. Anderson, Hogarthy, & Reiss, and Falloon, Boyd, McGill, Razani, Moss, & Gilderman, both cited in Razali, Hasanah, Khan, & Subramaniam, 2000) involves family psychoeducation regarding schizophrenia, social skills training, and communication skills training, all of which are widely accepted and effective treatments for schizophrenia. For ethnic minorities, culturally modified family therapy uses culturally sensitive explanations of schizophrenia, medication, and social skills training and had better long-term effectiveness in a Malay population than BFT (Razali et al, 2000). Perhaps the most researched family intervention for schizophrenia is that described in the "expressed emotion" (EE) literature. High EE is charac100

PERSONAL1TY-G VIDEO THERAPY FOR DEPRESSION

terized by a great deal of criticism of the identified patient, excessive involvement in the patient's life, and high expressed hostility. High EE has been shown to be a predictor of relapse (psychosis and hospitalization) in schizophrenia (e.g., see Hooley & Licht, 1997). Reduction of EE using family behavior therapy to reduce criticism, hostility, and overinvolvement led to dramatic reductions in relapse. BFT has been used successfully as an intervention in high-EE families (Falloon et al., cited in Razali et al., 2000; Hahlweg & Wiedemann, 1999); to the extent that a family with a person with schizotypal PD has high EE, BFT is likely to be helpful. Family theorists noted that double-bind communication patterns occurred in families with a schizophrenic member (Watzlawick, Beavin, & Jackson, 1967). Double-binds refer to messages that contain a directive at one level and a counterdirective at another level and that block escape. A classic example is the "be spontaneous" paradox. If a wife orders her husband to "be spontaneous," then if he acts in a spontaneous fashion he is doing so under her direction and therefore is not truly spontaneous; if he does not do so, then he is openly defiant. Watzlawick et al. (1967) hypothesized that the husband in this situation becomes psychotic to escape from the bind. Initially, Watzlawick et al. believed that double-binds from the parents caused schizophrenia in the child, but the theory was quickly modified to note the circular nature of the interactions, in which participants with and without schizophrenia would double-bind one another (see Burbach, 1996). Modern theorists have noted that a biological predisposition is necessary (but not sufficient) to cause schizophrenia, and the same can be said for schizotypal PD. When double-binds do occur, they are typically emotionally destructive, whether or not they cause psychosis. The way to break a double-bind is to address the underlying paradox through assertiveness and related means. For example, instructing the client to say, "When you tell me to be spontaneous, you put me in a no-win situation. I can't be spontaneous by command. How am I supposed to do that?" requires a response from the other person that will help to break the bind. The identified patient can also be instructed to own his or her experience and share it—for example, "When you order me to 'be spontaneous,' I feel trapped and manipulated." In this way, the context is shifted from a struggle for power to a discussion of feelings. A third way out is to directly confront the underlying power issue (e.g., "I understand you want me to be spontaneous, but that's not my goal"). This brings the power struggle out into the open where it can be directly addressed. Group Therapy Group social skills training can be especially helpful because the client can get feedback from peers rather than from the therapist alone. An important caveat for persons with schizotypal PD is that they must be socially appropriate enough to bond with the group and to avoid peer rejection. A former client of mine, "Pat," who had schizotypal PD, attended a group I ran. This SCHIZOTYPAL PERSONALITY DISORDER

101

group, a psychoeducation group for individuals with spinal cord injury, rarely included individuals with severe psychopathology, and due to the heavy dose of structure in the group, rarely elicited excessively intense emotions. We were discussing anger management, and I asked about how various individuals handled their anger. One said he counted to 10; another, that he rarely got angry; and a third said he yelled. Pat noted that when he got angry with his brother, he ran him over with a car. The room fell into a stunned, tight silence. I began to wonder if Pat was not only schizotypal, but actually schizophrenic. I pulled Pat from the group and began to see him in individual therapy. The main theme of the brief therapy was reality orientation. Most group therapy clients of mine, however, including those with schizotypal PD, have not alienated themselves in this manner and have profited from the generally accepting and nonjudgmental tenor of the group.

COUNTERTRANSFERENCE The literature on countertransference responses to individuals with schizotypal PD is extremely limited. As discussed in chapter 4, this volume, on schizoid PD, Giovacchini (1979) noted feelings of "existential terror," or a primitive fear of nonexistence, which often led to feelings of hopelessness with his schizoid patients (similar to modern schizoid and schizotypal PDs). Robbins (1998) referring to the "autistic position," discussed countertransference responses such as a feeling of vagueness and disconnection in response to the client's devastating isolation. Sadness, perhaps related to pity, also becomes prominent. Students describing their emotional reaction to individuals with schizotypal PD checked off words such as curious, bewildered, weird, perplexed, disconnected, and pity. Such reactions are consistent with schizotypal pathology (Bockian, 2002a). The individual is eccentric and strange, and tends to elicit odd feelings from the therapist. Such feelings can go in the direction of feeling curious—for example, about the experience of the client or the meaning of the loosely connected ramblings—or the therapist may experience feelings of pity, seeing the person's strangeness as being fundamentally sad. Many people simply cannot relate to these clients' quasi-delusional statements nor to their stiff or awkward style; feelings of disconnection may then result. In working with individuals with schizotypal PD—or with a psychotic disorder, for that matter—I find it helpful to view their statements as metaphors, interpreting them as poems or allegories. For example, a client has a delusion that he is being followed by beings from another planet. The meaning of that will vary from person to person, but there are a number of likely scenarios: The person feels invaded, intruded on, but also important (important enough that the beings chose him as a target). Translating from the 102

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

client's beliefs to the likely underlying meanings and understanding those underlying meanings generally shifts my emotional reactions from a felt sense of weirdness, and perhaps a bit of anxiety, to a sense of empathy. The underlying meanings are usually common, shared human reactions. Who among us has not felt intruded on at one time or another? Or wished that we were esteemed, or a bit more important than we probably are? Incidentally, as I look back on the days when I would directly share my insights with clients, I now consider this a clinical error on my part. Their beliefs were concrete— they were being followed by aliens! The most direct approach was to ask how it felt for the person to establish a sense of connection; it can be helpful to guess ("It must be frightening to you"). Unlike strange cognitive distortions, the underlying emotions are usually quite understandable. At that point, an empathic bond is generally readily established.

SOCIAL CONSIDERATIONS AND DIVERSITY As noted by Rollo May (1983a) and Victor Frankl (1983), modern life leaves people vulnerable to the struggle to find meaning in their existence. Traditional societies, through their more intense community involvements and religious beliefs, are unlikely to engender the belief that life is meaningless (Castillo, 1997). In technological societies constructed of tens or hundreds of millions of people, the belief that society would go on pretty much identically whether one participates or not can lead to thinking that one's contribution is trivial and that there is no purpose in one's existence. American society's great strength is its valuing the potential of each individual, but this individualism comes at a cost: If each individual is going in his or her own direction, it is difficult to find secure collections of individuals sharing meaning systems. If this feeling of ennui is relatively widespread among healthy, high-functioning, and privileged members of our society, imagine how much more difficult life is for the individual with constitutional proclivities for cognitive slippage who is isolated from others; subject to peer rejection; and, in many cases, not highly productive at work.

STRENGTHS OF PERSONS WITH SCHIZOTYPAL PERSONALITY DISORDER A number of studies have found a positive connection between schizotypal personality and creativity (Cox & Leon, 1999; Kinney, 20002001; Schuldberg, 2000-2001). A surprising positive relationship was discovered between the Schizotypal scale of the Millon Clinical Multiaxial Inventory—III (Millon, 1994) and quality of life (Bockian, Dill, Fidanque, & Lee, 1999). On examining the data, Bockian et al. (1999) found that the SCHIZOTYPAL PERSONALITY DISORDER

103

mean scores on the Schizotypal scale were very low. The most likely interpretation was that moderate scores on the Schizotypal scale were associated with the improvements in quality of life; hypothetically, this may be due to improved creativity. Imaginativeness and openness to alternative perspectives are likely to be strengths in many people with Schizotypal PD, especially those with a mild case. SYNERGISTIC TREATMENT Millon (1999) suggested modest goals for the individual with schizotypal PD, given their significant impairments. Establishing a relationship based on unconditional positive regard is essential as a foundation for other approaches and is healing in its own right. Often, practical advice and reassurance is warranted and can further deepen the trust in the relationship. Once the relationship is firmly established, cognitive interventions can decrease the quasi-delusional distortions the person experiences. Psychopharmacological interventions may be helpful as well in that regard and may also be useful in anxiety management with the timorous schizotypal subtype. As noted above, the client's eccentricities can elicit rejection, which can be iatrogenic; however, with adequate assessment and preparation, the group experience can be particularly healing in this population. Individuals with schizotypal PD often benefit from interpersonal contact that is nonthreatening and structured, as is often found in group interventions. Millon did not specifically recommend psychodynamic approaches as part of the synergistic sequencing; however, in this population, strong transference reactions can develop, which must be addressed. The porous line between reality and fantasy makes individuals with schizotypal PD particularly prone to distorted beliefs about the therapist. Further, the relative lack of outside relationships can heighten the importance of the therapeutic relationship. Psychodynamic theory is particularly useful in providing a conceptual map for traversing this potentially tricky terrain. Family interventions are often indispensable in creating a supportive structure that will allow the person to function outside of therapy. Millon's recommended strategic goals and tactical modalities are listed in Exhibit 5.1. CASE EXAMPLE: HOPE Technically, the case that follows would be diagnosed "personality change secondary to a medical condition [stroke]." That being said, the personality that resulted from the change would best be described as schizotypal PD. There was a substantial depression as well, which interacted with the schizotypal features to create a marked clinical presentation. To date, this client is the most prototypical example I have seen of someone with depression and schizotypal PD. 104

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

EXHIBIT 5.1

Therapeutic Strategies and Tactics for the Prototypal Schizotypal Personality STRATEGIC GOALS Balance Polarities Stabilize erratic pain-pleasure polarities Stabilize erratic self-other polarities Counter Perpetuations Prevent social isolation Undo excessive dependency Reduce fantasy preoccupations TACTICAL MODALITIES Alter eccentric behaviors Reverse autistic cognitive style Reconstruct estranged self-image Note. From Personality-Guided Therapy (p. 627), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

Hope was a 68-year-old divorced mother of six grown children. She grew up in an African nation and had been residing in the United States for approximately 40 years. A number of months before I began to see her, Hope had had a stroke or similar episode. This event led to her transition from community residence with her granddaughter to living in a nursing home. Christian throughout her life, following the stroke she became a Baptist and was "reborn." Since that time, according to her daughter, she was extremely religious. Her memory was somewhat impaired and thus some of the details in her history were sketchy. I had no difficulty connecting with Hope; unlike many people with schizotypal PD, she was interested in having a relationship with me and with her family members. I have often found that in nursing homes, because of the understimulating and often isolating environment, clients are eager for a relationship. Simply providing an opportunity to talk about her concerns established a comfortable therapeutic rapport. Hope's initial complaint to me was that she was seeing "devils," shadowy spirits that would hide in corners or under her bed. She claimed that they were stealing her clothes and otherwise tormenting her. Sadly, Hope's clothing was disappearing and needed to be replaced by the nursing home; staff believed that in fact the clothing was being stolen. Nonetheless, several diagnostic possibilities jumped to mind. Psychosis secondary to stroke and its attendant brain damage? Schizophrenia? Schizotypal PD? Atypical psychosis? Hope's voice was sad and pleading as she reported her story, and I felt a distinct cry for help. Paying attention to my emotional reactions to her, 1 SCHIZOTYPAL PERSONALITY DISORDER

105

noticed that I felt sad, heavy, and helpless, and I experienced a strong urge to rescue her. This is a common gut reaction I have noticed within myself when I encounter a client with depression, especially if the person has a tendency toward dependency. With clients who are more classically psychotic (e.g., those who have schizophrenia), I often experience confusion and a struggle to create coherence. Hope, however, was more in the schizotypal range of functioning—she was having illusions, rather than frank hallucinations; she probably did see shadows or vague movements on the ground but interpreted them to be demons. Behavioral eccentricities emerged in the course of treatment, as will be seen below. I believed, then, that the best way to initially conceptualize the case was major depression with mood-congruent delusions in the context of schizotypal PD. Because the belief in spirits is common in Hope's African culture of origin, the content of her thoughts was not particularly bizarre (L. Black, 1996). Interpreted as if they were poems or dreams, the experiences she shared seemed to indicate feelings of vulnerability and helplessness as she wrestled with forces outside her control. I believed that the intervention I provided should help her to feel empowered and in control and should help to increase her feelings of independence. Working collaboratively with her, I directed her feelings of dependency and reliance toward her faith, as I believed that her reliance on God was a strength in this case. My initial intervention could be conceptualized as behavioral or as paradoxical. At one level, I was providing a simple directive, a homework assignment. At another level, I was placing her in a therapeutic double-bind, in which I challenged her to eliminate her symptoms within the framework of her interpretation of her experience; the model on which 1 was drawing was Ericksonian hypnosis. Within the session, I said to her, Hope, you and I both know that spirits such as the ones you describe feed on misery and find the presence of joy intolerable. If you bring about within yourself a feeling of happiness the devils will leave you alone. What are some of the things that make you happy?

The primary activities that gave her joy were praying and attending church. "That is great," I said to her, "because you and I both know that the devils are powerless compared with the overwhelming power of God." I suggested that she "pray for happiness and inner peace in addition to your usual prayers." In addition to assigning the client this homework, I contacted her family to see if they could help get Hope to some of her meetings. Over the course of the next few sessions (I was seeing her twice per week), Hope's mood rapidly improved, and the frequency with which she saw the "devils" rapidly declined. Staff reported—some with amusement and others with irritation—that Hope at times was praying in loud, fervent songs. She also began to preach, to no one in particular. She reported success in attaining joy, especially when she sang out to the Lord with all her 106

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

heart. Within approximately 3 weeks she was delusion free. She was freely talking about her feelings, such as difficulties adjusting to the nursing home and frustrations regarding insufficient time with her family. It is worth noting that unlike her belief in spirits, her decision to pray loudly and preach from her bed would be considered eccentric or inappropriate within her subcultures (African American and Baptist), thus the schizotypal diagnosis. A variety of family and community interventions were also extremely helpful. I interacted with Hope's oldest daughter fairly regularly; she visited Hope about once every 2 weeks. I helped make arrangements for Hope to go to her religious meetings, working with lay leadership in the community and with her family. Still, Hope only got to go about once per month, though that made a huge difference in her life. At one point, Hope lost weight, was looking pale, and appeared to me to be dying. I checked with her physician, who confirmed that she was having difficulty staying hydrated and was not doing well; death at any time was not out of the question. Working with her oldest daughter, we arranged to have as many family members as possible come to visit. Her brother flew in from Africa to surprise her, and probably a total of a dozen family members came to visit. As the family members visited, I could see the life pouring into her body. She fully recovered and regained her prior level of health. Hope continued to wrestle with difficulties maintaining her grip on reality throughout treatment. Under stress, she would become delusional again, and, when more distressed, she would occasionally become frankly psychotic. She had a hallucination that a large, terrifying devil was standing menacingly at the foot of her bed, leaning over her in an intimidating and threatening manner. Repeating the intervention for her to pray and to engender joy in her life was helpful. The larger, more intimidating figure may have represented death, fused with guilt. At that time, she was having an erotic transference and may have had guilt about her sexual feelings. Thus, the therapy began to move into areas most thoroughly addressed by psychodynamic theory. 1 have noticed that strong transference reactions often occurred in my nursing home clients; their lives were often understimulating, and thus the therapy took on a higher level of prominence. Her feelings for me represented, at least in part, unresolved feelings that she had about a man she had wanted to marry but from whom she was kept apart, primarily for racial reasons. I also represented an idealized father image, because her true father was neglectful and philandering and was thrown out of the house by her mother. Over time, after gleaning a variety of meanings regarding her prior relationships, our bond became more reality based. We terminated more because I was leaving the setting than because of a natural termination time. Hope was in therapy with me for about 2 years, and probably could have gone on for at least a year more. Termination was done over a period of several months and ultimately went smoothly. SCHIZOTYPAL PERSONALITY DISORDER

107

SUMMARY AND CONCLUSIONS As illustrated in the case of Hope, a personality-guided conceptualization, followed by a catalytic sequence of interventions, led to substantial improvements. The interplay of her depression and her vulnerability to quasidelusional ideas as a function of her schizotypal PD meant that both problems had to be treated simultaneously. After establishing rapport, an individual intervention based primarily on paradoxical techniques helped to improve the client's mood and decrease her quasi-psychotic experiences; indeed, one might say that the client's willingness to act in an odd manner (singing in a public setting) enhanced her recovery. Understanding of her culture and of what her experience meant to her was particularly critical in this case and shaped the nature of the paradoxical interventions. Family interventions, cognitive interventions to challenge her irrational beliefs, and psychodynamic conceptualizations to understand and ultimately confront issues in the client-therapist relationship (the transference-countertransference dynamics) were integrated in accordance with her schizotypal personality. Emphasizing her strengths helped to enhance her relationships within her family and led to long-term more positive functioning. Notably, medications were not necessary in this case; it is not necessary to automatically refer for medications in these cases, though, of course, medications should be used as a resource when indicated. Per the above discussion, I suggest that key areas for research include studies that look at the catalytic arrangement of interventions based on personality-guided principles. It may be necessary to evaluate subtypes independently (e.g., Millon's distinction between the schizotypal with avoidant vs. schizoid features). Medication research is important, not only to find more effective medication agents but also to assess which cases may not need medication intervention.

108

PERSONAL1TY-G UIDED THERAPY FOR DEPRESSION

6 DEPRESSION IN ANTISOCIAL PERSONALITY DISORDER

So apt at capturing the essence of human nature, Shakespeare illuminated the character of the scheming lago, who, speaking of Othello, declares, I follow him to serve my turn upon him: We cannot ail be masters, nor all masters Cannot be truly follow'd. You shall mark Many a duteous and knee-crooking knave That, doting on his own obsequious bondage Wears out his time, much like his master's ass, For naught but provender; and, when he's old, cashier'd: Whip me such honest knaves . . . In following him I follow but myself; Heaven is my judge, not I for love and duty, But seeing so for my peculiar end. (Shakespeare, 1972, pp. 1171-1172)

The bard delineated the hallmarks of what we now call the antisocial personality disorder (PD): being self-centered and manipulative. People with this disorder view the world as a savage place divided into exploiters and the exploited—and they choose and vigorously pursue membership in the former group. Although it is often tied to violent criminal behavior, especially on 109

the lower socioeconomic rungs, the passage illustrates how sociopathy can penetrate the highest social echelons. lago also has elements of narcissistic PD, as will be discussed in a later chapter.

PHENOMENOLOGY: THE EXPERIENCE OF ANTISOCIAL PERSONALITY DISORDER People with antisocial PD tend to be impulsive and tough. In more severe cases, conscience is entirely lacking; in virtually all cases, conscience is extremely deficient. As the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) put it, The essential feature of Antisocial Personality Disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood, (p. 701) Among those who are violent, most use violence instrumentally. There was an appropriate category in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) for those who use violence for sadistic pleasure; however, with the elimination of aggressive-sadistic personality disorder in the fourth edition (American Psychiatric Association, 1994), the closest category in DSM-IV-TR is antisocial PD. People with this disorder are often, for example, manipulators, con men, or parasites who fleece others of their savings or live off others without any thought of reciprocation. Much of my experience with individuals with antisocial PD has been with drug dealers and substance abusers who sustained spinal cord injuries from their high-risk behavior (e.g., being shot during a drug deal or having a car accident while driving under the influence). Establishing rapport was a challenge, although I found this to be workable'within the hospital setting. In chapter 7, this volume, on borderline PD, I describe the case of an individual who had a mixture of borderline and antisocial features. The therapy went well, because we were able to control the contingencies shaping his behavior effectively; in that case, the behaviors generalized well postdischarge, and he changed his life in a positive way. In purer cases of antisocial PD, I have been able to achieve substantial changes using similar methods during clients' hospital stays, but few of these changes tended to be internalized, and my sense was that these clients were quick to revert to their old ways. Establishing rapport with this help-rejecting population can be difficult; methods to effectively establish a preliminary rapport are discussed later in this chapter. Individuals with antisocial PD often have a peculiar kind of empathy. Noted Millon (1996), "Antisocials tend to be finely attuned to feelings, moods, 110

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

and vulnerabilities of others, taking advantage of this sensitivity to manipulate and control. However, they typically evidence a marked deficit in selfinsight and rarely exhibit foresight" (p. 464). Therapists often observe this phenomenon during therapy sessions, experiencing themselves a feeling of vulnerability and invasion when working with such clients. EPIDEMIOLOGY Community estimates indicate that antisocial PD occurs in approximately 3% of males and 1% of females. In clinical settings, the prevalence is approximately 3% to 30%, whereas in substance abuse and forensic settings the prevalence is generally even higher (American Psychiatric Association, ZOOOa). In a sample of depressed clients, approximately 3% had antisocial PD (Fava et al., 1995). Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; none had antisocial PD. In a sample of 249 depressed outpatients, none were diagnosed with "definite" and 2% were diagnosed with "probable" antisocial PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). In Pepper et al.'s (1995) dysthymic disorder sample, 4% had antisocial PD. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 7.8% had antisocial PD. In a sample of 352 clients with both anxiety and depression, approximately 2% had antisocial PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). In the depressed samples reviewed, then, approximately 0% to 8% had antisocial PD. Beginning with the portion of the sample in which antisocial PD was reported, Zimmerman and Coryell (1989) found that 34.6% had depression. HOW DO PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER GET DEPRESSED? Impulsive and acting-out behaviors tend to protect individuals with antisocial PD from depression. When they do get depressed, it is often because they have been constrained in some way, usually by the legal system. Individuals with other psychiatric problems, such as schizophrenia, may become depressed in inpatient psychiatric settings once their psychosis is in remission. On the spinal cord injury unit, some clients had fears of reprisals from others. To some degree, their fears were probably justified; others whom they had harmed may have been eager to pay them back. To some degree, these fears were also probably a projection of their own hostile feelings. Because they are impulsive and often have comorbid substance abuse, however, depressed individuals with antisocial PD are at high risk for suicide (Links, Gould, & Ratnayake, 2003). Unlike most PDs, which create a vulnerability ANTISOCIAL PERSONALITY DISORDER

I11

to depression, in the case of antisocial PD there is a unique Personality x Environment interaction (antisocial PD plus constraint) that increases not only the likelihood of depression but, more important, its lethality. Such a conceptualization is consistent with the "pathoplasty" model of interaction between the Axis I and Axis II conditions. Another unusual feature of antisocial PD is that the presence of depression appears to improve treatment outcomes, as reported by Woody, McLellan, Luborsky, and O'Brien (cited in A. T. Beck, Freeman, & Davis, 2004, p. 12); this is a kind of reverse "exacerbation" model of the interaction between antisocial PD and depression (see chap. 2, this volume, for a discussion of the theoretically possible relationships between depression and personality disorders).

HOW A PERSON BECOMES AND REMAINS ANTISOCIAL: THEORIES OF ANTISOCIAL PERSONALITY DISORDER Antisocial PD and its youthful counterpart, conduct disorder, are the most thoroughly researched of all the PDs with regard to causality. Research reviewed below provides detailed estimates of genetic versus environmental contributions. In addition, a considerable amount of theory has been generated in an effort to understand the thoughts and behaviors of this enigmatic group. Perhaps this is due to our natural fascination with the "criminal mind," or the cost to society, both economic and emotional, associated with antisocial acts. In addition to considering individuals with criminal behavior, this section will consider the broader issues associated with the active self-oriented person. Biological Factors The biological mechanisms underlying antisocial PD features, such as impulsivity and aggression, are related to serotonergic activity in the brain. Coccaro (1998) reviewed some 30 studies demonstrating a relationship between serotonin levels and impulsive aggression. Serotonin levels, as measured by cerebrospinal fluid metabolites, demonstrated an inverse relationship with impulsive aggression. Low serotonin levels were associated with, among other indicators of impulsive aggression, violent suicide attempts, impulsive arson, violent assaults, and lifetime history of aggression. Pharmacologic challenge studies demonstrated reduced response to serotonergic agents in individuals with impulsive aggression. Platelet studies suggested an inverse correlation between the number of serotonin-binding sites and impulsive aggression. Activity level in the frontal lobes, such as the orbital frontal region, has been shown in a variety of studies to be associated with impulsive aggression. Perhaps the most famous case is that of Phineas Gage, a 19th-century rail112

PERSONALITY^ VIDEO THERAPY FOR DEPRESSION

road worker whose anterior and medial frontal cortex was damaged by a spike through his head. Gage underwent massive personality changes, most notably an increase in aggression and impulsivity. Since then, formal studies have documented that dysfunction and reduced levels of activity in the frontal region are associated with aggression, impulsivity, and criminal behavior (see Siever et al., 1998). Heritability

Nigg and Goldsmith (1994) reviewed studies that used the Psychopathic Deviate scale (Scale 4) of the Minnesota Multiphasic Personality Inventory. Studies of normal twins yielded a heritability of approximately 56%; similarly, a study of twins raised apart yielded a heritability estimate of 61% on the same scale (DiLalla, Carey, Gottesman, & Bouchard, 1996). Loehlin, Willerman, and Horn (1987) administered the Minnesota Multiphasic Personality Inventory to mothers who were giving up their children for adoption; years later, they tested the adopted children at about the same age as the mother when she was tested. The correlation between the scores was .27, which suggests a heritability of .54; by comparison, the correlations with adoptive relatives were negligible (.02, .07, and .01 for adoptive siblings, fathers, and mothers, respectively). A study using the Dimensional Assessment of Personality Pathology Callousness Scale yielded a heritability of 56%, whereas stimulus seeking had a heritability estimate of 40% (Jang, Livesley, Vernon, & Jackson, 1996). Studies of conduct problems have yielded heritability estimates of 61% (Coolidge, Thede, &. Jang, 2001) and 49% (Livesley, Jang, & Vernon, 1998), although surprisingly, a different study found a heritability estimate for conduct disorder of zero (Livesley, Jang, Jackson, & Vernon, 1993). A meta-analysis by McCartney, Harris, and Bernieri (1990) showed a higher interclass correlation for monozygotic twins (.49) than dizygotic twins (.29) on aggression. The sum of the evidence suggests that antisocial PD and antisocial traits are moderately heritable, as is the case with the other PDs. Medications Theoretical work reviewed above has indicated that serotonergic pathways in the frontal area are implicated in impulsive aggression, thus suggesting that selective serotonin reuptake inhibitors would be effective in reducing acting-out behavior. Studies done with individuals with borderline PD have borne out these predictions in open trials (Markovitz &. Wagner, 1995), uncontrolled studies (Silva et al., 1997), and a double-blind, placebocontrolled study (Rinne, van den Brink, & Luuk van Dyck, 2002). Such studies should be replicated with individuals with antisocial PD. Some preliminary investigations have been done with atypical antipsychotics for antisocial PD. Hirose (2001) presented a case study in which treatment with risperidone led to reduced aggression and impulsivity. ANTISOCIAL PERSONALITY DISORDER

113

T. Walker, Thomas, and Allen (2003) studied 4 participants using quetiapine; like Hirose, they noted reductions in aggression, impulsivity, hostility, irritability, and rage reactions. In the absence of further studies, it is worthwhile to consider the clinical observations of Joseph (1997). He argued that antisocial PD can be conceptualized as falling along a number of dimensions, some of which are amenable to intervention with medications and others of which are not. Joseph noted that impulsivity may indicate attention deficit disorder or hypomania. As is well known, attention deficit disorder can be treated with stimulants (e.g., methylphenidate), bupropion, or various other medications, and hypomania responds to lithium, carbamazepine, sodium valproate, and so on. As discussed above, irritability and anger respond to serotonergic medications; if those medications are not effective, antipsychotics or benzodiazepines can be tried. Unfortunately, as Joseph noted, treatment is often unsuccessful; in part, this is due to the numerous symptoms of the disorder that medication cannot reduce. Criminal behavior, exploitive conduct, irresponsibility, and deficient conscience are, and may always be, beyond the reach of pharmacological intervention. He recommended working with patients, their families, and the courts to develop realistic expectations of what medications can and cannot do in these cases. That being said, Joseph noted that medications can be very helpful in some cases, especially if the antisocial features are intertwined with paranoid ideation; in such cases, antipsychotic medication can make an enormous difference. Although Joseph's (1997) recommendations are rational, his hypotheses are not a substitute for ongoing theory building and empirical investigations. Scientific studies must be performed to assess the efficacy of medications with antisocial PD. Until a solid base of randomized clinical trials of various medications has been created, the usefulness of various medications will remain in doubt. Psychological Factors The biopsychosocial model (Millon, 1969) indicates that a person's biological makeup, psychological experiences, and social (e.g., cultural, ethnic, and religious) environment all contribute vital information for understanding an individual. Each element of this model will be reviewed in the following sections. Millon s Theory According to Millon (1969, 1981, 1996, 1999), individuals with antisocial PD are the "active-independent" type. They are thought to have a generally active, impulsive nature, perhaps because of inadequacies in the "pain" center of the brain and densely branched neuronal networks in centers that regulate anger. These neural problems may have been caused by 114

PERSONAllTY-G HIDED THERAPY FOR DEPRESS/ON

genetics or shaped by experience. The early experiences of people with antisocial PD are likely to be characterized by conflict. Noted Millon (1981), The primary experiential agent for this pattern is likely to be parental rejection, discontent, or hostility. This reaction may be prompted in part when the newborn infant, for constitutional reasons, proves to be "cold," sullen, testy, or otherwise difficult to manage. It does not take too long for a child with a disposition such as this to be stereotyped as a "miserable, ill-tempered, and disagreeable little beast." Once categorized in this manner, reciprocal negative feelings build up into a lifelong cycle of parent-child feuding, (p. 208) During infancy, from birth through 1 year of age, this hostile relationship is already beginning to take root. By early childhood, these children are already rebelling and, feeling unsafe, are relying on themselves for protection. As they mature into grade school and adolescence, they increasingly develop a deviant, outsider identity, distancing themselves from the counsel of others who may be older and wiser. Evidence from the Environmental Risk Longitudinal Twin study (Trouton, Spinath, & Plomin, 2002; see also Jaffee et al, 2004) supports and extends Millon's theory regarding the early manifestations of the antisocial pattern and the environmental sequelae. This study examined over 1,100 twins drawn from, a registry of over 15,900 twins born in England and Wales in 1994 and 1995. Families in which mothers were 20 years of age and younger were selected because maternal youth is associated with risk for problematic outcomes. Children were followed from approximately age 5 to age 7. Researchers found that corporal punishment was genetically mediated but that physical abuse was not, indicating that abuse was due to factors that differed among families. The genetically mediated factors that underlie corporal punishment, however, were also correlated with antisocial behavior. Overall, then, children with certain genetically mediated characteristics (e.g., oppositional, aggressive, and coercive behaviors) are more likely to be spanked; physical discipline, in turn, increases the risk of antisocial behavior. Abuse, however, is added on, coming more from other family factors (e.g., parental characteristics; Jaffee, Caspi, Moffitt, Polo-Thomas, et al., 2004). In terms of environmental risk factors, abuse has been shown by Cicchetti and Manly to be a risk factor for antisocial behavior (cited in Jaffee, Caspi, Moffitt, Polo-Thomas, et al., 2004). The longitudinal twin study quoted from below suggests in the strongest possible way that abuse plays a causal role. Jaffee, Caspi, Moffitt, and Taylor (2004) ruled out numerous alternative explanations to support their conclusion. They noted, We found that (a) physical maltreatment prospectively predicted antisocial outcome, (b) physical maltreatment bore a dose-response relation to antisocial outcome, (c) physical maltreatment was followed by the emergence of new antisocial behavior, (d) children's maltreatment vic-

ANTISOCIAL PERSONALITY DISORDER

115

timization was not influenced by genetic factors, (e) the effects of physical maltreatment remained significant after controlling for parents' history of antisocial behavior, and (f) the effect of physical maltreatment was significant after controlling for any genetic transmission of antisocial behavior, although genetic factors accounted for approximately half of the association between physical maltreatment and children's antisocial behavior. (Jaffee, Caspi, Moffitt, & Taylor, 2004, p. 50)

Maternal negative expressed emotions are also a risk factor for later antisocial behavior and, on the basis of similar logic, also appear to play a causal role. Mothers who made negative comments (e.g., "she is horrible") and who had an overall negative tone (e.g., more negative comments than positive ones) were more likely to demonstrate antisocial behavior concurrently and prospectively, controlling for genetic factors; the researchers also statistically eliminated the possibility that the negative expressed emotions were purely a function of the effects of the child's behavior on the parents, using longitudinal analyses (Caspi et al., 2004). Scientists are beginning to identify genotypes that moderate the relationship between environment and antisocial behavior. One study, which followed participants from birth to adulthood, examined over 500 men at age 26. They found that a gene-impacting monoamine oxidase A had a moderating effect; high levels of this enzyme reduced the likelihood of antisocial behavior occurring in the presence of maltreatment (Caspi et al., 2002). A variety of factors serve to perpetuate the antisocial PD pattern. The person with antisocial PD's anticipation of distrust elicits genuine distrust from others, thus initiating a cycle of mutual misgivings. Their proclivity for being provocative elicits hostility from others, justifying their worldview that others are cruel and vindictive. Finally, their weak intrapsychic control leads to the direct venting of angry feelings or to impulsive behavior; thus, they are continually in difficult legal and interpersonal situations, perpetuating their view of the world as hostile and unjust (Millon, 1999). The description of the antisocial PD prototype in terms of Millon's domains is presented in Appendix B. Of the features listed, "irresponsible," "acting-out,'' and "impulsive" are the most salient. Cognitive-Behavioral Conceptualization and Interventions Individuals with antisocial PD are prone to a variety of automatic thoughts that flow from their cognitive schemas and core beliefs. Automatic thoughts include, "I cannot let him get the better of me"; "It doesn't matter, I'll just get high"; and "I'm going to get what I want (regardless of what happens to anyone else)." A. T. Beck, Freeman, and Davis (2004) described six categories of cognitive distortions that typify the antisocial prototype: 1. Justification—"Wanting something or wanting to avoid something justifies my actions." J 16

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

2. Thinking is believing—"My thoughts and feelings are completely accurate, simply because they occur to me." 3. Personal infallibility—"I always make good choices." 4. Feelings make facts—"1 know I'm right, because I feel right about what I do." 5. The impotence of others—"The views of others are irrelevant to my decisions, unless they directly control my immediate consequences." 6. Low impact consequences—"Undesirable consequences will not occur or will not matter to me." (p. 175) As noted previously, most people with antisocial PD are prone to depression when they are constrained. For such individuals, their beliefs typically include thoughts such as "I am trapped," "I will never get out of here," "I've gone too far this time," "I can't possibly survive this horrible place long enough to get free." I have also seen similar thoughts in individuals with substance addiction; often, in a sudden burst of insight, they realize they are in a prison just as real as one with walls and bars. The chemical slave driver dictates their every behavior, from theft to prostitution to losing jobs to living on the streets. Perhaps they have tried drug rehabilitation and it has failed, or perhaps the thought of asking for help is worse than dying. A patient of mine (see the case example in chap. 7, this volume), while having such thoughts, injected his veins with battery acid in an attempt to die. I remember shuddering with revulsion when I heard about his choice of method, as if the only way to destroy himself would be to consume and obliterate himself from the inside out. The distorted beliefs of both the depressed and nondepressed individual with antisocial PD can be challenged using standard cognitive techniques, such as Socratic dialogue and thought records (J. S. Beck, 1995). Behavioral contracting is another technique that I have found to be helpful in my work with individuals with antisocial PD (Bockian, 1994). I have never used individual contracts (i.e., contracts that just involve patients contracting with themselves, such as agreeing to reward themselves for behaviors associated with quitting smoking). Instead, all of the contracts I have done have involved individuals with antisocial PD as they are involved in a system and details of how they would interact with one another. Most of these have been contracts to reduce or eliminate verbal or physical abuse. It is a fundamental tenet of behavioral contracting that everyone must think the contract is fair, which can be quite challenging when one party has issues of entitlement. Nonetheless, I believe I was always able to find common ground on which to agree. Even individuals with severe antisocial PD recognize that a hospital will not agree to allow them to abuse staff, particularly in writing. I always made sure that there was something in it for the patient. For example, in one case, the client was concerned that he was not ANTISOCIAL PERSONALITY DISORDER

117

always given smoking privileges. As part of the behavioral contract, I scheduled in four smoking sessions per day. This provided a real incentive for him to participate in the process. In that case, a nurse complained that although the client was the abusive one, it was the staff who had to make all of the behavioral changes. Although that was not quite true—there were numerous behavioral consequences that were initiated by the patient's behavior— I could understand her point. Most of the behavioral changes were mediated by restructuring the patient's environment, which meant changing staff behaviors. I replied that she was right and that in a perfect world, the client's immoral and problematic behaviors could be changed in a direct way. However, the only way to change his behaviors was to change his environment— namely, our behaviors. Because we were the ones drawing salaries, and it was incumbent on us to rehabilitate the patient (including psychological rehabilitation) as part of our mission, we would have to go first. However, I reassured her that if about 100 years of behavioral theory had merit, then his behaviors should follow shortly. Once they did, I never had to deal with that complaint again when contracts were written for other clients. Individuals with antisocial PD tend to also be receptive to cost-benefit analysis interventions, which provide structured ways to look at long-term and short-term benefits of a particular action. Because they are interested in having their short-term needs gratified, there is an incentive to participate. By looking in a structured way at typical interactions, the client will often come to see how a little bit of planning can yield greater gratification in the long term (A. T. Beck et al., 2004; A. T. Beck & Freeman, 1990 ). Psychodynamic Therapy

Psychodynamic theory can be helpful in understanding the inner world of persons with antisocial PD. Their internalized objects are generally malevolent and perceived as hurtful and exploitive. Akhtar (1992), in his summary of a large psychodynamic literature, stated succinctly, Most psychoanalytic investigators agree that the core antisocial character results largely from a severely traumatized childhood, with much actual injustice being suffered by the growing child. Internalization of abnormal parental superegos or unconscious parental encouragement of the child's delinquency are other common background factors. Disappointment in primary objects, humiliation and suffering, internalization of abnormal norms, and/or corruption by parents are various factors that work with the child's own age-specific distortions and fantasy elaborations, (pp. 229-230)

These factors lead to a severe disturbance in the clients' internalized objects as well as in their interactions with others. Nonetheless, the use of psychodynamic treatment techniques in cases of true antisocial PD is generally futile. Millon (1999) noted that there are

118

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

few intrapsychic mechanisms on which patient and therapist can draw in such cases. He concluded, There is a widespread pessimism as to whether intrapsychic therapy can produce significant changes within the antisocial . . . psychodynamic approaches tend to be difficult to undertake because antisocials are not apt to internalize therapeutic "insights" without external controls or interventions, even if they stay in treatment for more than a few sessions. If severe limits are put on the antisocial personality (such as in highly controlled incarceration settings), anxiety and depression may lead some patients to be more amenable to change. Almost any other treatment orientation would have a greater (if limited) chance at success given the antisocial's lack of insight and low tolerance for boredom or slowly progressive changes, (p. 480)

O. F. Kernberg, Selzer, Koenigsberg, Carr, and Appelbaum (1989) were more succinct, stating simply in a footnote that their treatment, which at the time was called expressive therapy, is contraindicated in cases of antisocial PD (p. 8). That Kernberg, who successfully opened the door for psychodynamic treatment of borderline and other severe personality disorders, was so blatantly pessimistic about treatment of individuals with antisocial PD is a powerful indication that other therapies should be used in such cases.

COUNTERTRANSFERENCE The client with antisocial PD, like the client with narcissistic PD, routinely rejects the therapeutic relationship. In such a circumstance, the therapy often stalls; the therapist often responds with feelings of helplessness. Ironically, despite such feelings, therapists may take excessive responsibility for the client's behavior, perhaps as a function of omnipotence fantasies. When the client acts out, the therapist may then feel responsible and thus guilty (Strasburger, 1986). Helpless feelings may also induce the belief that treatment is futile (Lion, 1978; Meloy, 1988). Many therapists see themselves as nurturing and kindhearted; such characteristics are often devalued by the person with antisocial PD. To the extent that the therapist accepts the client's feelings, the therapist experiences devaluation and invalidity, which produces feelings such as worthlessness, depression, anger, and shame (Strasburger, 1986). These clients' lack of emotional nuance and subtlety may also be disconcerting to therapists, disrupting their normal ways of relating and leaving them feeling unbalanced. Therapists will often reject, hate, or wish to destroy clients with antisocial PD because of their immoral behavior and the powerful reactions the clients elicit. In psychodynamic theory, one might say that the clinician's superego is activated against the id-driven behaviors of the client (Meloy,

ANTISOCIAL PERSONALITY DISORDER

119

1988; Strasburger, 1986). For example, when a client has raped someone, the therapist may fantasize about the client receiving castration as therapy or the death penalty as punishment. Though this is not the venue to discuss the appropriate severity of punishment for crimes, it is clear that such fantasies represent great anger and likely hatred as well. The therapist must be comfortable with these emotions, which are not unnatural, and use them in the service of the therapy; consultation with colleagues can be important in such cases. Therapists often feel manipulated by individuals with antisocial PD; indeed, such clients can pull for special treatment. Therapists must understand their motives for "bending" their usual practices. Usually, changing one's standard practice is a bad idea, because therapists can inadvertently reinforce clients' erroneous belief that it is other people's inflexibility or misunderstanding that is the problem rather than their own dysfunctional behavior (A. T. Beck et al., 2004). One emotional reaction therapists often have to the antisocial client is fear of assault or harm. This is a realistic fear and should be honored. Existing data suggest that attacks on therapists are fairly common; for example, Guy, Brown, and Poelstara (1990) found that nearly 40% of psychologists have been physically attacked on one or more occasion. It appears that "serious" attacks (in which the psychologist misses 1 or more days from work) are rather rare, with 3% of psychiatrists and 1% of psychologists reporting such attacks (Reid & Kang, 1986). Several leading theorists have noted that therapists may defend against the anxiety of real danger by psychological denial (Gabbard & Coyne, 1987; Meloy, 1988; Strasburger, 1986). Lion and Leaff (1973) asserted that such beliefs and defenses are disturbingly common; they noted, "Denial is the most ubiquitous defense against anxiety generated by a violent patient. ... to face the issue of dangerousness is very threatening to the physician . . . the therapist's human vulnerability emerges" (p. 105). I know of several cases in which sociopathic clients have assaulted therapists. In one particularly disturbing case, a therapist who was in denial about the dangerousness of a patient used harsh confrontational techniques on a psychiatrically hospitalized and still unstable sociopathic man; to make matters worse, the therapist had a student with her. When the patient, who stood approximately 6 feet, 2 inches tall, became assaultive, the confronting therapist fled, followed by her student; the patient was able to catch, beat, and injure the student. It is essential to take appropriate measures to assure therapist safety, especially maintaining physical superiority (i.e., having sufficient staff of sufficient strength and with appropriate training to safely and quickly control a patient). Our discipline must confront denial in our students, our colleagues, and ourselves. Sometimes, this denial is related to a belief that our "special relationship" with a client is a sufficient safeguard. Instead, careful attention to verbal and nonverbal cues and awareness of the client's motivation and capacity for self-control are better indicators; in addition, sys120

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

temic issues (e.g., safety protocols that are in place in a hospital or clinic) are key. With appropriate precautions, however, fear of assault need not and should not dominate the treatment or lead to intimidation of the therapist. Research on graduate students' responses to filmed vignettes of individuals with antisocial PD suggested that they initially respond to these individuals with feelings of curiosity, sadness, and pity; they also feel alarmed, irritated, fearful, afraid, and angry (Bockian, 2002a; see the description of the study in chap. 1, this volume). Informal discussions with the study participants have indicated that the pity they felt was mostly related to characteristics specific to the client portrayed in the film vignette (Wohl, 1996); he appeared to have a low IQ and, given his history of violence, rather meager prospects for the future, even if he were able to turn his life around. The person portrayed elicited somewhat more compassion than most, because he was treated, apparently successfully, and was making the film vignette as a way of thanking his therapists.1 Consistent with the literature reviewed above, the feelings of anger and irritation were generated by his sociopathic behavior, such as his violence, especially his violence toward women. Feelings of alarm and fear were realistic responses to the client's propensity for violence and extremely marginal internal controls. In reflecting on my own work with individuals with antisocial PD, there are a few whom I liked, but mostly I felt wary, guarded, and suspicious. Even with those who were "nice," I was generally waiting for the other shoe to drop, such as a request to collude against other members of the treatment team. I used to try getting in touch with their abuse history as a way of stoking my feelings of compassion; in my experience, this was worse than futile. All had been abused, and all responded with denial ("It wasn't so bad" or "I deserved it") or withdrawal from any of my expressions of compassion. Perhaps accepting compassion was interpreted by the client as a form of inferiority in a hierarchical relationship. It is also possible that despite my conscious efforts to avoid it, I would slip into feeling pity, from which most people shrink (whether they have antisocial PD or not). Instead, I now do the work internally. I imagine that the person was abused and is responding the best way he or she knows how. I pay attention to any somatic responses I am having, such as leaning forward, leaning back, or tightness in the stomach; usually, I experience tension of some kind when there are dominance issues (e.g., if I am being insulted or drawn into a power struggle). 1 then work hard to sidestep such conflicts, knowing from experience that they are futile; as noted in prior examples, I do this by providing suggestions and stating, "It is up to you if you choose to do what I suggest." I challenge my beliefs using cognitive techniques. For example, if a client then does not take my suggestions, I have thoughts such as, "He should do as I 'The interested reader can view the film clip of this discussion in the antisocial PD case on the video Diagnosis According to the DSM-IV (Wohl, 1996).

ANTISOCIAL PERSONALITY DISORDER

121

suggest, his life is a mess, and that is his only way out of trouble." This belief can be challenged on numerous grounds: Getting out of trouble may not be his goal; he may consciously or unconsciously crave the structure of his present setting. Also, it really is his life, and it only affects me to the extent that I invest some part of myself in him; I need to return to neutral. What am I getting out of his doing what I suggest? Let it go. Further, what does the behavior mean to him? There are people who have sacrificed their lives for a cause. Patrick Henry is a hero for having given his life for his country. We admire him, because we admire his cause. To individuals with antisocial PD, any cause for which they are willing to give their lives invariably seems fool' ish to me, from my perspective, but to the person with the disorder, it is all important. (This dynamic can be found in the case example in chap. 7, this volume, on borderline PD. The patient literally risked his life by failing to comply with his routine medical care. Eventually, I understood that he be' lieved that to be under the control of another was worse than death. In his mind, he was behaving like Patrick Henry.) In such circumstances, one can challenge the meaning of control; for example, working through administrative channels to control the nurses' behaviors rather than cursing at them may be an acceptable substitute behavior. One can also challenge the client's black-and-white thinking that he or she must be in control of everything at every minute. Such a change would involve giving trust, something with which the individual has had horrible experiences. Such challenges to my beliefs help me to stay focused and recognize how difficult it is for that person to behave in a manner that would meet my expectations. In most cases, I am accustomed to reframing the belief that large changes can occur in therapy. Not to be unduly pessimistic, but I believe that a superego must be developed during a certain sensitive period. One cannot put yeast in the dough, leave it on a shelf for 25 years, put it in the oven, and expect to get bread. Thus, in the case of the individual with antisocial PD, I can be more satisfied with small changes. However, I do believe that if these small changes are sufficient to get the person into a dramatically different environment, great change can occur. For example, if the client gets into a stable relationship with a genuinely caring and drug-free individual, then the changes that can occur over long periods of time with a significant other providing corrective emotional experiences on a daily basis can be almost miraculous. In my clinical experience, life events outside of psychotherapy that unfold over a number of years are often crucial to the client's ability to make major changes.

SOCIAL CONSIDERATIONS AND DIVERSITY Antisocial PD occurs approximately 3 times as frequently in males as in females (DSM-IV-TR, p. 704), a finding for which there are a variety of 122

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

explanations. There could be genetic, hormonal, or other biological factors that account for the difference. Males, more than females, may be given messages that it is acceptable to express anger. In addition, there could be diagnostic bias. Many males are labeled antisocial who would probably be better conceptualized as borderline (Dutton, 1998; Hart, Dutton, & Newlove, 1993). If men with borderline PD express their rages by hitting others, if drug use is their form of impulsive behavior, and if they then get into drug-related legal problems, the behavioral line between borderline PD and antisocial PD becomes thin. Nonetheless, the underlying biological and psychological factors can be different, even diametrically opposed. Individuals with borderline PD are hypersensitive in a variety of domains; individuals with antisocial PD tend to be hyposensitive. The emotional force of an intervention that will merely touch a person with antisocial PD will be experienced by the person with borderline PD as a hammer blow. People with borderline PD may be prone to shame and guilt, unlike those with antisocial PD. Perhaps most important, individuals with borderline PD are relationship oriented and are more capable of forming a therapeutic alliance. My advice is that a clinician should carefully rule out borderline PD on any male diagnosed with antisocial PD. I have observed that failing to recognize borderline pathology in men with antisocial features has done a good deal of harm. Borderline PD is more treatable, and therefore misdiagnosis leads to lost opportunities for recovery. As noted previously, features of antisocial and narcissistic PDs were induced in randomly selected college-aged men in the famous Stanford prison experiment (Haney, Banks, & Zimbardo, 1973). Collins (1998) extended this finding by having college student participants rate behaviors as either masculine or feminine; consistently, the guard behaviors (dominance, aggression) were rated as masculine, whereas prisoner behaviors (depression, anxiety) were rated as feminine. Because all of the participants were the same gender and were randomly assigned, the only plausible explanation for the differences in behavior was social role. Collins concluded that social dominance tends to elicit arrogance and oppressive behavior, whereas social status inferiority elicits feelings of helplessness, depression, and anxiety. Although not a conclusive study, Collins's findings lend weight to the notion that at least part of the explanation of the gender gap in antisocial PD is the impact of male privilege and patriarchy on mental functioning. The issue of masculinity is crucial when treating males with antisocial PD. The culture of psychotherapy promotes a number of values: introspection, vulnerability, processing feelings, self-awareness, and open communication. These are feminine-typical strengths. Male strengths include task focus, courage, expressing opinions, assertiveness, and team play (Bockian, 1999). Individuals with antisocial PD often have several of these strengths. The most important idea I try to keep in mind is that it is not necessary to change the client's masculine traits to have a good outcome. He does not ANTISOCIAL PERSONALITY DISORDER

123

have to become sensitive, sentimental, or highly introspective. The research literature teaches us that androgynous individuals are no better adjusted than individuals who are highly masculine (Basoff & Glass, 1982; Choi, 2004; Whitley, 1983, 1985). Thus, it is incumbent on us to accept various aspects of the client's approach to the world that may not match our own. Instead, it is wise for the therapist to take advantage of potential masculine strengths to engage processes that are necessary for therapy. For example, honesty is essential. When the client says something honest that leaves him vulnerable, I acknowledge him by saying something like, "That took a lot of guts to admit that you made a mistake. Now we can get to work. Let's roll up our sleeves." Here, I engage courage in the service of honesty and vulnerability, task focus, and teamwork. An intervention I did with Doug, a patient with borderline PD (see the case example in chap. 7, this volume), was an attempt to gain honor among thieves, so to speak. He was breaking some rules on the unit and was saying he would not do it again. I asked him to "give me his word as a man" that he would no longer engage in the behaviors, which he did. When he repeated the behaviors (which I partially expected despite the hope that he would change), I said to him, in a surprised and disappointed tone of voice, "You gave me your word as a man, and then you broke it? It'll be quite some time before I trust you again." Doug had a mixture of borderline and antisocial features, so a "pure" antisocial might have responded differently, but after that intervention, he worked hard to earn my trust. I had provided him with a challenge and an opportunity. He could be a man; in an institution such as a hospital, one is treated like a child in many ways. He rose to the occasion. Antisocial PD is more likely to occur in cultures that are hierarchically arranged. Extremely common thoughts among individuals with antisocial PD include "I'm not getting my fair share"; "Why should he have it and not me?"; and "I want it, so I'm going to get it." Disparities in wealth and status provide targets for the antisocial agenda.

STRENGTHS OF PERSONS WITH ANTISOCIAL PERSONALITY DISORDER If they can be channeled for the good, many characteristics of antisocial PD are adaptive and even admirable. The ability to be charming and to create a sense of trust—if one follows through with trustworthy behaviors— constitutes an extremely important set of social skills. The aggressiveness of the antisocial person, when sublimated, is a positive trait. The "aggressive" athlete is usually admired above all others, and to call someone an aggressive businessperson or salesperson is generally a compliment. Subclinical or normal-range antisocial features are often present in some of the most successful people in our society. 124

PERSON AllTY-G U1DED THERAPY FOR DEPRESSION

TREATMENT PLANNING: SYNERGISTIC TREATMENT In working with the depressed person with antisocial PD, it is extremely important to establish a therapeutic relationship. There are a variety of ways to do so, which have been outlined elsewhere (Bockian & Jongsma, 2001), though it should be noted that none of these strategies is entirely effective. Conceptually, I consider the client as having no superego, and thus I must work entirely through the ego and the id. Depression is a positive prognostic sign because it will provide motivation for the person to change. The depressed person with antisocial PD, unlike the "pure," nondepressed antisocial person, is confronted with the thought, "This ain't working." Perhaps he has gotten caught by the police doing something illegal and is now in prison, or perhaps he is court-ordered into treatment, or perhaps he is in a mental institution, and it bothers him. I then frame our relationship as one in which I am a consultant who will help the client to achieve his goals, within reason. On the spinal cord injury unit, I worked on numerous occasions with patients who were verbally or even physically abusive with staff. What I found fascinating was the underlying rationalization. The client usually framed the situation as one in which the nurse was not doing her job (e.g., by not bringing his water immediately or by insisting that he do something for himself). He would then experience something akin to an obligation to correct her shortcomings. (Presumably, this was a reenactment of his childhood experience through identification with the aggressor, though I rarely confirmed this assumption.) Once I ferreted out the meaning of the behavior, assuming that the client did interpret the problem as being that he was getting poor service, I would say something like the following to the client: Therapist:

You know, when you yell, scream, or curse at a nurse, the hospital labels that verbal abuse. And the hospital is required by law to provide an abuse-free environment for its employees. So the minute you start cursing out a nurse, the entire resources of the hospital will be directed at getting you to stop. No matter how high they have to escalate, they'll keep going. Is that what you want, to be battling the whole hospital?

Client:

That is so unfair. Why should I have to wait for 20 minutes just to get a glass of water? Why do I have to sit here with my f ing hair in my f ing eyes just because Jane [the nurse] is on her coffee break.7 And why don't they leave my brush where I can reach it? They do it just to piss me off. They're just trying to get under my skin.

Therapist:

It's true. It's not fair for you to have to wait a long time for your care. But cursing them out just gets you in trouble, and it doesn't get you what you want. Hey, do you really want to bust her?

Client:

How? ANTISOCIAL PERSONALITY DISORDER

125

Therapist:

Client: Therapist: Client: Therapist:

Client: Therapist: Client:

Talk to Jill McDonald. She's the patient advocate. She talks to the chief of staff. Your complaint will go to Jane's bosses' bosses' boss. Does that really work? I've seen it work 100 times. That might be all right. How do I contact her? I'll tell her today that you want to see her. She usually sees patients within a day or two. By the way, you know you can have these nurses eating out of your hand, don't you? What do you mean? They became nurses in order to help people. They're a bunch of do-gooders. It's really easy to get them to do what you want. How?

Therapist:

All you have to do is throw in a couple of "thank you"s after they give you your care.

Client:

But that's their job! I shouldn't have to thank them for doing their job. They're getting paid for that.

Therapist:

You and I both know that people should do their jobs well whether they get thanked or not. I'm just telling you, that's what makes them tick. You have to stick with it a few times for it to work, but if you try it, you'll see. It's up to you; it doesn't make any difference to me.

Such an intervention, when combined with specific behaviors on the part of nurses, was successful with 7 of the 8 abusive patients that I saw on the spinal cord injury unit; the 8th patient was a person with multi-infarct dementia. The essential behavior on the part of nursing staff, when they were abused, was to state, "That is abuse. I will return when you can behave appropriately." The nurse would then leave the room. Thus the antisocial individual's desire for instrumental control was undermined. In the above intervention, 1 took into account a number of conceptual issues. One was to work within the client's worldview. In the us-and-them battle for control, I helped the client to see that he was isolated and badly outgunned (which was why we, the staff, had to present a united front). I then offered him a potentially powerful ally—the chief of staff of the hospital—who was more powerful than the entire force against whom the client was fighting. I validated the portion of the client's position that was reasonable (it was not right for him to have to wait an excessive length of time for treatment). By telling him to complain, I implied that he had just cause. Of course, it was not my call either way. If the client had asked me if I thought he was right—which none ever did—I would simply have shared this fact

126

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

with the client (e.g., "What, I have to do Jill's job now, too? Talk to Jill, and see what she says. If you're still not happy, there are other things we can do"). In the entire process, the client was moving toward a position of working within and through the system rather than working outside of it. If that lesson sinks in—and it did in most though not all cases—it is the most powerful lesson of all. I also taught clients to "manipulate" in a sophisticated rather than a crude fashion. Many of us will say "thank you" to a nurse who helps us because, well, we actually feel grateful. This is too much to hope for in the early treatment of individuals with antisocial PD. In fairness to the clients, their upbringing was probably miserable and punitive, and thus to get to true gratitude will at a minimum take time or may never occur. If the client changes from manipulating cruelly and harmfully to kindly and productively, I'll take that deal. My slight derogation of the nurses was also strategic. To say that as a whole they were a good and kind group was so outside the client's realm of experience that it could not even be processed. That they were "a bunch of do-gooders" says the same thing, though it was framed by the client as indicating that they were suckers or manipulators. Nonetheless, the client received and integrated the powerful message that he could work with these people on their own terms; could get a certain amount of what he wanted; and the nurses would be so happy, they'd come back for more! The final piece of the intervention is among the most important. I withdrew my investment in the client's decision, keeping him in charge and maintaining my role as a consultant. If I had become an authority figure, our alliance would have been shattered. The overall functioning of the system was crucial in these instances. Jill McDonald (not her real name) truly was phenomenal at resolving conflicts and understanding the perspective of both parties. Nursing staff, with excellent uniformity, followed through on setting boundaries. It should be noted that as human beings, the nurses were responsive to ordinary reinforcements, and the clients' hostile behaviors did elicit passive—aggressive behaviors from some nurses. However, on the whole, the nurses really were goodhearted and responded well to a few "thank you"s. Poorly functioning systems with deeply entrenched hostility and political divisions may not have done so well with such interventions. In terms of catalytic sequences, then, I would recommend an integrated cognitive—behavioral/systemic approach as illustrated by the above when possible. Environmental contingencies, when controllable, can provide a context for behavioral change. Although accurate empathy and unconditional positive regard are building blocks for the relationship, warmth, at least in my experience, is not. A warm, sensitive male is viewed as weak by the typical person with antisocial PD and may arouse homophobia; I have found that being warm with them is tantamount to a request for premature termination. My experience base with these clients is almost exclusively in ANTISOCIAL PERSONALITY DISORDER

12 7

EXHIBIT 6.1 Therapeutic Strategies and Tactics for the Prototypal Antisocial Personality STRATEGIC GOALS Balance Polarities Shift focus more to needs of others Reduce impulsive acting-out Counter Perpetuations Reduce tendency to be provocative View affection and cooperation positively Reverse expectancy of danger TACTICAL MODALITIES Offset heedless, shortsighted behavior Motivate interpersonally responsible conduct Alter deviant cognitions Note. From Personality-Guided Therapy (p. 474), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

male-male relationships. Other arrangements are likely to elicit very different responses. I have female students who have acted warmly with male antisocial clients and obtained excellent results, though in all of the cases I can recall there was a rapid erotic transference that had to be resolved before further progress could be made. It is also noteworthy, then, that the procedure I have outlined may need to be modified for female therapists or clients. Guidelines for treatment goals were summarized by Millon (1999; see Exhibit 6.1). As noted, it is critical to balance the self-other polarity by shifting more toward others' needs and to decrease the "active" end of the active-passive dimension by reducing impulsive acting out. It is essential to block activities that perpetuate the antisocial pattern, such as clients' tendency to be provocative and their proclivity to view cooperation as problematic. The clinician needs to intervene to reduce shortsighted behavior, irresponsible conduct, and distorted cognitions.

CASE EXAMPLE: JOE At the time that he was seen by his therapist, Joe, a 25-year-old African American man, was incarcerated on charges of murder and home invasion. He was being held in secure custody, 23-hour lockup, in solitary confinement. At the time of the initial evaluation, Joe was extremely depressed. He had attempted suicide by hanging himself using his bedsheet; it was accidental that he was found and cut down. His suicide attempt prompted the refer-

128

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

ral, though he had the full spectrum of symptoms that qualified him for a diagnosis of major depression: He was not eating and had lost weight, was lethargic and apathetic, and had feelings of hopelessness. Joe also clearly met the criteria for antisocial PD. He had a lengthy juvenile record (e.g., truancy, vandalism, and violent behaviors). Joe was a gang member and had moved up to a high level on the hierarchy. He thrived on the excitement and sadistic pleasure of the gang fights. He would continue to beat his victims after they were unconscious. Later on, Joe was involved in extensive criminal activity but was never convicted because he or his gang members were consistently able, through the threat of physical violence, to intimidate people into dropping the charges against him. Once that started to happen, Joe began to feed off the feelings of invincibility and power, and his grandiosity began to soar. Freed from what minimal constraints he previously had had, his behavior became increasingly daring. He developed a scheme to rob other gangs by dressing up as police, busting into their houses, and taking money and stolen goods; this activity was highly lucrative. His luck ran out when he decided to hit a major gang a second time; this time around they were prepared, and a gunfight ensued. Joe accidentally shot and killed a young child and was charged with the crimes for which he was presently incarcerated. Joe's older brother, younger sister, and his mother were also involved in gangs. His father, who had been absent from the home for years, was a pimp. His mother was killed in a gang fight. In his mind, his mother's gang did not retaliate adequately for her death. Plotting the best path for revenge, he dropped out of school at 16, joined a rival gang, and figured out the best way to hurt others. During his 1st year in the penitentiary, Joe wanted to attain the high rank that he had held in his street gang. To "prove his worth," he engaged in dozens of violent incidents, incurring multiple prison charges. He quickly became unmanageable within the institutional structure. Prison authorities cracked down and broke up the gangs within the prison. Their main weapon was the use of solitary confinement. Repeatedly placed in solitary confinement, Joe became increasingly morose. It was at this time that he attempted suicide and was offered treatment. The therapist, Don Castaldi, connected with him through empathy and validation. He provided the client with an opportunity to discuss his situation and vent his anger. From the client's perspective, it was easy to understand how difficult it was to be sent to solitary confinement so often. Dr. Castaldi would make statements such as, "I can imagine how awful it must feel to be sent to secure lockup"; "It is understandable that you are angry when you get sent to solitary so often"; and "It must be frustrating to get sent to solitary so often, while others do not." The key was to validate the feelings, not necessarily the cognitive interpretation of the inequities and "unfairness" that are a function of externalization of blame.

ANTISOCIAL PERSONALITY DISORDER

129

Having established a working alliance, Dr. Castaldi set out to reframe the client's behavior and his role in the power hierarchy of the prison subculture. He asked the client, "You're a smart guy, but you're always the one getting pitched [put in solitary]. Why is that?" The client noted that others would start up with him, and he "had to show them who's boss." The therapist wanted to challenge the client's concrete and short-sighted notions of challenge and control and to highlight the consequence of getting "put in the hole" over the momentary power of winning the fight. He took a bit of a risk by using a confrontational and irreverent (Linehan, 1993) style. He stated, "Oh, so you're the entertainment." Enraged, Joe terminated the session. After about a week, however, Joe sent a message requesting another session with Dr. Castaldi. Joe asked what was meant by the comment about being the entertainment. Dr. Castaldi explained that some of the inmates were intentionally, though indirectly, provoking Joe by sending others to press his buttons. By responding predictably, Joe was turning over his power and allowing himself to be used, that is, manipulated like a puppet. Joe could not deny the accuracy of the description, and his worldview changed radically in that moment; he no longer wanted to dance to their tune. However, it was not clear to Joe how he could save face. He was able to internalize that not fighting was being strong and smart. This kind of "cost-benefit" analysis, which involved evaluating actions in terms of his personal gain and loss, was congruent with his personality style. He began to covet the instigator role instead, seeing if he could get others to dance to his tune. In fact, he was able to wrest some control in that manner. His fighting decreased substantially. And because other prisoners were not as easily provoked or sadistic as Joe, and were less damaging fighters, there was a dramatic reduction in the overall violence on the ward. Joe, working behind the scenes, gained power among the inmates. At this time, the staff sergeant began to communicate with Joe to get a feel for the emotional tone of the unit, which instigated a process of inmates' respecting one another's areas of expertise and power. Once he was no longer being sent to the hole and began feeling more in control, Joe's depression and hopelessness dissipated. Joe was now able to plan more effectively and think more abstractly. True, he was using his skills to be manipulative, but he was doing so in a manner that was causing far less social harm and personal distress. At this point, Joe was looking forward to his sessions and consistently was waiting to meet Dr. Castaldi at the appointed time. Dr. Castaldi noted, in retrospect, that he began to feel narcissistic gratification from treating this case. He felt himself getting drawn into being invested in certain outcomes, such as behavioral and attitudinal improvements. Here was this "impossible" client, with whom he was having astonishing "success." Other staff members in the prison were taking note of him, and his prestige was rising. Suddenly, but inevitably, the therapist's prestige on the unit was tied to Joe's behaviors. Subtly, this was shifting the dynamics 130

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

of the treatment into an old and all-too-familiar pattern for Joe, someone using him for personal gain. Dr. Castaldi discussed the case with a colleague, who noted how much pressure to succeed this case was generating. Looking at the issues allowed Dr. Castaldi to get a greater sense of perspective. He focused on becoming more mindful and viewing Joe as a person rather than a "project," which helped him to regain his balance. Simultaneously, Joe was experiencing something of an identity crisis. No longer invested in creating an illegal empire, he was not sure what to do or who he was. He began to identify with the African American subculture and focus on issues of racial oppression. Other African American prisoners also started to pressure him about seeing a White therapist, which strained the therapeutic relationship with Dr. Castaldi. Joe began to feel conflicted about being open and vulnerable with his "oppressor." Dr. Castaldi, on the other hand, felt frustrated with Joe's distorted and separatist interpretation of Martin Luther King Jr.'s work and with Joe's focus on fighting racism as an excuse for violence. Joe increasingly asked difficult questions relating to Dr. Castaldi's assessment of him as a person. This culminated in the following exchange: Joe: Dr. Castaldi: Joe: Dr. Castaldi:

Joe:

You know, I could kill you if I wanted to. Yes, I know. Does that intimidate you? It would, but I know that you are working toward becoming a better you, and that killing me would blow everything you've worked toward, so that reduces my fear. If I'm frightened I can't do my best work with you, so I really kind of let it go. You said that so easily.

Dr. Castaldi:

Whether you can defeat me in a fight is not very important to who I am. It's just the truth.

Joe:

I've had to think about whether I could take someone or they could take me every day of my life. I can't even imagine any other way of thinking.

Dr. Castaldi's genuineness had an enormous impact on Joe, who suddenly realized that life could be very different. Dr. Castaldi's recognition and validation of Joe's physical strength seemed reassuring in that context. They were able to discuss the impact of racism and social class in a more productive and collaborative way so that Joe could integrate his own behaviors with the impact of racism and social class to create a more realistic picture of his life and his situation. He began to show remorse, demonstrating feelings for the young boy who had been killed by his stray bullet and acknowledging that he had stolen that child's opportunity to experience life. At about this time, other gang members were beginning to testify against him in court. Joe ANTISOCIAL PERSONALITY DISORDER

J 31

began to state that he wanted to "honor the memory of the child" by turning state's evidence. Dr. Castaldi noted that there were several elements in his decision, including genuine feelings for the child as well as self-serving interests (e.g., avoiding life in prison). It was difficult to assess just how far Joe had come in developing a conscience or superego, but it appeared that he had developed at least a minimal or preliminary concept of and experience with guilt and remorse. His basic self-serving approach was still dominant, and as he appeared to be transitioning from a deviant to a more mainstream set of values and convictions, Dr. Castaldi was struck by how Joe was able to give up "the code," that is, the gang values that he presumably had held all his life. After testifying, Joe was transferred to another prison where he apparently served 5 years and was released; Joe had viewed testifying as "being in the spotlight" and had enjoyed the narcissistic gratification. At their last contact, Joe told Dr. Castaldi that he would miss their conversations; Dr. Castaldi said he believed that Joe had great potential and wished him the best. Dr. Castaldi believed that the main impact of therapy had been the opportunity for Joe to internalize a positive relationship as well as Joe's ability and decision to take advantage of this opportunity. Treatment had lasted approximately 1 year. In sum, then, Dr. Castaldi followed the principles of personality-guided therapy by modifying his approach to Joe on the basis of Joe's personality style. The initial connection with Joe was established through a relationship style that is possibly unique to the treatment of individuals with antisocial PD: The therapist was empathic and validating but not particularly warm or nurturing. The therapist then used cognitive and interpersonal techniques and theory, which helped the client to develop a different understanding of his relationships on the ward. His choice of how to deliver the message about how he was being "played" by other inmates, which was a gut-level therapeutic intervention, was consistent with dialectical behavior therapy (Linehan, 1993) and paradoxical communication concepts (Watzlawick, Weakland, & Fisch, 1974). Behavioral techniques are implicit in prison life, because there is a system of rewards and punishments to enhance compliance with ward routines. However, the impact of the behavioral consequences was entirely contingent on the client's conceptualization of the consequences; thus, in this case, cognitive work was essential in complementing the behavioral plan. Once the client did some basic reframing, however, the behavioral consequences began to have their intended effect. The second major turning point in the case, the client's confrontation of the therapist regarding the client's superior strength and the way the therapist handled it, is an excellent example of the powerful impact of therapist genuineness (Rogers, 1979). Psychodynamic thinking also impacted the analysis of this powerful transference response on the part of the client. His reaction to feeling vulnerable (i.e., to threaten, assert power, and take control) was met in a different and therapeutic way. Presumably, Joe was anticipating 13 2

PERSONAL1TY-G UIDED THERAPY FOR DEPRESSION

posturing, defensiveness, or power plays by Dr. Castaldi; when the latter reacted with honesty and empathy, it smashed his assumptions about the nature and potential of relationships. The amelioration of Joe's depression occurred naturally as a consequence of attending to the environmental and relationship issues that accompany antisocial PD. The Axis I and Axis II conditions were treated as a unified whole rather than as two separate conditions. As Joe's behaviors, cognitions, and relationships changed, the depression dissipated.

SUMMARY AND CONCLUSIONS Treating the person with antisocial PD starts with some extraordinary challenges in establishing rapport, the difficulty of which is second only to the treatment of clients with paranoid PD. Clients with both depression and antisocial PD are usually somewhat more amenable to treatment because they want some kind of change, and the therapist may be able to help. Extreme bluntness and an appeal to the client's self-interest while making modest demands often suffice to establish a starting place; warmth and compassion, central with treating other disorders, is usually an error with this population. Synergistic and catalytic sequences for the person with antisocial PD can then follow. Cognitive and behavioral strategies aimed at securing desirable consequences are usually a good place to start. Once the trust is established, interpersonal strategies may be useful. Psychodynamic approaches are useful for conceptualization, and the skilled use of confrontation can be essential to success; it should be noted, however, that few individuals with antisocial PD have much patience for the thorough efforts required in many analytical approaches. As illustrated by the case of Joe, genuineness and transparency were keys to the client's breakthrough, as was an understanding of the transference and countertransference. Future research should focus on an empirical analysis of ways of establishing rapport in this population to validate the growing clinical lore on the topic; many therapeutic interventions fail because they cannot get past this first step. Brain research also seems to be a particularly promising avenue; findings may lead to early intervention strategies or medication interventions. Finally, the empirical analysis of the arrangement and integration of psychotherapeutic approaches, including synergistic and catalytic sequences, requires further empirical investigation.

ANTISOCIAL PERSONALITY DISORDER

13 3

7 DEPRESSION IN BORDERLINE PERSONALITY DISORDER I Feel I feel the whirlwind twisting inside me a great tornado tears me apart. I feel the hate burning inside fire and darkness blackens my soul. I feel the fear squeezing my heart incredible terror separates me from the world. I feel the emptiness deep as a well the huge black hole forever swallows me. I feel the pain need to die. Insufferable punishment can no longer live. —Brooke Bergan

PHENOMENOLOGY: THE EXPERIENCE OF BORDERLINE PERSONALITY DISORDER It is difficult to convey the emotional distress experienced by individuals with borderline personality disorder (PD). The disorder has the dubious distinction of having the highest rate of suicidal and parasuicidal behavior of any PD. Poetry and artwork can help to convey the anguish of those with the disorder. The poem above is by a young woman who had borderline PD, Brooke Bergan; she was in high school when she wrote it.1

'I am delighted to report that Brooke now describes herself as completely healed, through a combination of psychotherapy and intensive prayer, and she is now a professional writer (Brooke Bergan, personal communication, August 8, 2005). She requested that the following poem be included here to provide a complete picture of her recovery: "To My Father, God: / "Let my days start in Your presence / for just an hour or two / or all day long, for all I want / is to remain in You. / "I've wandered over rocky roads / and always in the end / I've ended up back in Your arms— / my broken heart you mend. / "For in this life trials will come / but in and through them all / Your loving arms will draw me on / to Heaven where I belong."

135

This poem illustrates the severe emotional dysregulation, the "swirling tornado" that consumes her, and the accompanying suffering, which she experiences or interprets as punishment. The fire produces burning (blackening) heat, but no light; it cannot push out the darkness. Fire and darkness coexist within her, representing the split she feels. She experiences hate, terror, and fear—her anger cannot protect her and perhaps only increases her feeling of vulnerability. In the end, everything is swallowed up by emptiness and the desire to end her pain through death. Her wildly fluctuating emotions lead to relationship disruptions, fueling abandonment fears that further her emotional dysregulation. Borderline PD was described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) as follows: "The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts" (p. 706)

EPIDEMIOLOGY Borderline is the most frequent of all PDs. According to the DSM-IVTR, 30% to 60% of individuals within personality disorder samples have a borderline diagnosis. Borderline PD is estimated to exist in 2% of the general population, 10% of individuals seen in outpatient clinics, and 20% of inpatients (American Psychiatric Association, 2000a, p. 708). In a sample of depressed clients, approximately 16% had borderline PD (Fava et al., 1995). Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 6.9% had borderline PD. In Pepper et al.'s (1995) dysthymic disorder sample, 24% had borderline PD. In a sample of 249 depressed outpatients, 2% were diagnosed with "definite" and 8% with "probable" borderline PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). In a sample of 352 clients with both anxiety and depression, approximately 14% had borderline PD as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Thus the frequency of borderline PD in samples of individuals with depression ranges from 2% to 24%. Likely reasons for the wide range include natural sample variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria (e.g., some studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 1980], and some used criteria from the revised third edition [American Psychiatric Association, 1987]). Starting with borderline PD and looking at depression, a study that included 175 clients with borderline PD found that 70.9% had major depression (McGlashin et al., 2000). Zimmerman and Coryell (1989) studied a 136

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

community sample of 797 individuals, which included 143 individuals who were diagnosed with PDs. Among individuals with borderline PD, 61.5% met the criteria for depression. According to a literature review on the frequency of comorbid conditions with borderline PD, 24% to 87% of individuals with borderline PD have affective disorders as well (Shea, Widiger, & Klein, 1992). WHY DO PEOPLE WITH BORDERLINE PERSONALITY DISORDER GET DEPRESSED? The reasons for depression among individuals with borderline PD are self-evident, because they are partially incorporated into the definition of the syndrome. Affective lability, which includes depressed mood, is one of the criteria for borderline PD. Consistent with the "psychobiological" model of the relationship between Axis I and Axis II, it may be that common biological factors partially underlie each disorder. The typical lifestyle of individuals with borderline PD only exacerbates the likelihood of depression. They deeply desire love and affection, but their erratic and unstable behaviors practically preclude the possibility of stable attachments. Although alcohol and illicit drug use may temporarily stave off painful affect, both the biological and psychological effects of substance abuse are depressogenic. Interpersonal dependency issues can be related to intense feelings of helplessness, which leads to depression (Seligman, 1975); in addition, clinging dependency can bum out relationships, leading to further distress. Individuals with borderline PD also have copious anger and rage, which can be directed against the self as a flood of recriminations (Millon, 1999). Thus borderline PD creates a vulnerability to depression, and further, each disorder exacerbates the intensity of the other. It is also reasonable to speculate that not only constitutional factors but also psychological events may predispose a person to both borderline PD and depression. For example, there is a relatively high rate of sexual abuse reported by individuals with both disorders (Danielson, de Arellano, Kilpatrick, Saunders, & Resnick, 2005; Freyd et al., 2005; Swanston et al., 2003; Whiffen & Macintosh, 2005; Zanarini, 1997).2 Borderline PD plus depression is a particularly dangerous combination. In one study, 92% of individuals with depression and borderline PD had a lifetime history of at least one suicide attempt. This rate was significantly higher than individuals with depression alone or with depression and a comorbid Axis II diagnosis other than borderline. Approximately 31% of the suicide attempts were rated as having a "severe" (e.g., cut throat) or "extreme" (e.g., coma) level of lethality (Friedman, Aronoff, Clarkin, Corn, &. Hurt, 1983). 2

See chapter 2 for further discussion of theoretical models of relationships between Axis 1 and Axis II disorders.

BORDERLINE PERSONALITY DISORDER

13 7

HOW A PERSON BECOMES AND REMAINS BORDERLINE: THEORIES OF BORDERLINE PERSONALITY DISORDER Biological Factors A number of biological factors have been shown to be related to incidences of borderline PD. Heritability

Borderline PD appears to be moderately heritable. In one study, a factor labeled "emotional dysregulation," which corresponds to borderline PD, had a heritability estimate of 52% (Jang, Vernon, & Livesley, 2000). Coolidge, Thede, and Jang (2001), in their sample of children and adolescents, found that the heritability of borderline PD is 76%. A study using the Dimensional Assessment of Personality Pathology found that affective lability has a heritability of 38.4%, and identity problems have a heritability of 39.7%. Silk (2000), in his review of the literature, estimated that the overall heritability of borderline PD is approximately 50% (pp. 66-67). Neurological and Neuropsychological Findings

Positron-emission tomography scans on several samples have demonstrated reduced activity in the brains of adults with borderline PD, particularly in the orbital-frontal region (Goyer, Andreason, et al, 1994; Goyer, Konicki, & Schulz, 1994). Studies by Soloff et al. (2000) with a sample of people with borderline PD demonstrated reduced response to the serotonin agonist fenfluramine relative to a placebo control. Using positron-emission tomography scans and magnetic resonance imaging, Ley ton et al. (2001) also found lower levels of brain activity near the frontal lobe area and differences in the serotonin-rich areas of the brain, concluding that low serotonin synthesis capacity in the relevant pathways of the brain may promote impulsive behavior in individuals with borderline PD. As seen in chapter 6, this volume, brain-scan studies have shown that individuals who have difficulty with impulse control and aggression have reduced levels of activity in their brains in a number of key locations. This effect held up whether one used lifetime history of impulsive-aggressive acts or current impulsivity on an assigned task to define impulsivity. Increases in aggression are associated with low level of activity in the frontal cortex as well as reduced activity in several areas within the limbic system. Although further research is necessary, these preliminary results imply that memory and integration of sensory and emotional material are implicated in the difficulties experienced by people with borderline PD. Similarly, studies using computerized tomography scans have demonstrated interesting neuroanatomical differences between individuals with and without borderline PD that correspond to clinical presentation. For example, J 38

PERSONALITY-G VIDEO THERAPY FOR DEPRESSION

one study showed that when compared with controls, while controlling for overall brain volume, people with borderline PD had a 16.0% smaller hippocampus and a 7.5% smaller amygdala (Driessen et al, 2000). The hippocampus plays an important role in memory, and the amygdala relates to a variety of emotional processes. Neuropsychological studies of individuals with borderline PD also provide highly useful and suggestive findings. O'Leary and Cowdry (1994) reviewed four neuropsychological studies done on people with borderline PD. They concluded that people with borderline PD demonstrate difficulties with visual discrimination and filtering and difficulties with recall of complex material. There also appear to be problems in visuomotor integration and figural memory. Neurological examinations and electroencephalogram studies have shown a high rate of subtle neurological dysfunction in individuals with borderline PD (Zanarini, Kimble, & Williams, 1994). These problems are generally in the mild to moderate range and are diffuse; thus they are subtle and could easily be missed without testing. Individuals with borderline PD have been found to have difficulty with both verbal and visual memory, especially with regard to complex material. Difficulty with recall of complex material may make it difficult for people with borderline PD to learn from their experiences. We do not yet know whether individuals with borderline PD have difficulty with retrieval, recall, or both. Processing problems can also impact an individual's self-image. O'Leary and Cowdry (1994) noted that "such a memory deficit may contribute to difficulties borderline patients experience in maintaining a continuous sense of self and using the past to respond to present events and predict future consequences" (p. 147). Thus, brain functioning and learning style may contribute to many of the difficulties that we see in borderline PD. A number of the findings are consistent with borderline psychopathology. Poor filtering often leads to confusion, which may contribute to excessive dependence on others and poor boundaries. Diffuse neuropsychological dysfunction may be related to dissociation and other neurocognitive functions. Sluggish functioning of the serotonergic systems, imbalances in the cholinergic and noradronergic systems, anatomical deficiencies in the amygdala, and dysfunction in the limbic system may lead a person to be extremely vulnerable to impulsivity and affective dysregulation. Deficiencies in the hippocampus may contribute to memory problems. Many of the distortions people with borderline PD evince may be seen as a function of neurological dysfunction. Splitting, for example, can be seen as a problem of recall especially in evidence under conditions of high emotional arousal. A natural question is whether the neurological problems are primary and cause borderline PD, whether borderline behavior causes neurological impairment (e.g., through substance misuse and head injury associated with high-risk behavior), or whether the problem is best explained by a third variBORDERLINE PERSONALITY DISORDER

J39

able (e.g., physical or sexual abuse, which leads to neurological impairment). At this time, there is insufficient evidence to answer the etiological question definitively. The various models are not exclusive, and any or all of them may be relevant in any given case. Medications

Medications that impact serotonin generally have had salubrious effects on individuals with borderline PD. Markovitz and Wagner's (1995) open trial investigation of venlafaxine with 39 patients demonstrated decreases in self-injurious behavior, somatic complaints, and Symptom Checklist—90 scores. Silva et al. (1997) did an uncontrolled 7-week trial of fluoxetine with 35 patients that showed decreases in depression, impulsivity, and overall psychiatric symptoms and an increase in Global Assessment of Functioning scores. Sertraline and citalopram appear to have decreased borderline symptomatology in an uncontrolled study (Ekselius & von Knorring, 1998; see chap. 1, this volume). Rinne et al.'s (2002) double-blind placebo-controlled study of 38 women demonstrated that fluvoxamine produces substantial decreases in rapid mood shifts, though aggression and impulsivity were not improved. Anticonvulsants have had mixed results, de la Fuente and Lostra's (1994) double-blind, placebo-controlled trial of carbamazepine with 20 inpatients showed no improvement on the Symptom Checklist—90, Brief Psychiatric Rating Scale, and an acting-out scale, and 2 participants in the medication group dropped out because of dramatic acting-out behavior (wrist cutting and physical violence). An 8-week, open-label trial (Stein, Simeon, Frenkel, Islam, 6k Hollander, 1995) of valproate with 8 patients found that there was overall improvement in about half the cases. Impulsivity, irritability, anger, anxiety, and rejection sensitivity showed modest improvements. Stein et al. (1995) concluded that valproate may have "limited efficacy" in treating borderline PD. Hollander and his associates (Hollander et al., 2001; Hollander, Swann, Coccaro, Jiang, & Smith, 2005, in two small randomized controlled trials with divalproex sodium, found decreased aggression, irritability, depression, impulsive aggression, and suicidality as well as improved global impression. In a study that was unique in that it focused on immediate effects, Philipsen et al. (2004) administered clonidine to 14 female participants and took ratings after 30, 60, and 120 minutes. There were significant decreases in inner tension, dissociative symptoms, and urge to commit self-injurious behavior; the effects were strongest after 30 to 60 minutes. Atypical antipsychotic medications have also shown promise in treating symptoms of borderline PD. Case studies have illustrated marked improvements in some individuals. Khouzam and Donnelly (1997) noted remission of extreme impulsivity and self-mutilation using risperidone, and Szigethy and Schulz (1997) found that a client with borderline PD and dysthymia responded to a combination of risperidone and fluvoxamine. Treat140

PERSONAL1TY-G UIDED THERAPY FOR DEPRESSION

ment with clozapine led to a dramatic decrease in self-injurious behavior after failed attempts with various other medications (Chengappa, Baker, & Sirri, 1995); similarly, a client with obsessive-compulsive disorder and borderline PD "improved considerably" with clozapine following failed attempts with numerous other medications (Steinert, Schmidt-Michel, & Kaschka, 1996). Cagno (2001) reported a case in which there were decreased psychotic symptoms, improved treatment compliance, and an improved "sense of purpose" (p. 344) in a client treated with quetiapine. Hilger, Barnas, and Kasper (cited in Markovitz, 2004) reported on 2 clients whose self-injurious behavior was eliminated at 6-month follow-up (Case 1) and 8-month follow-up (Case 2) following treatment with quetiapine. Self-injurious behavior was also reduced in 2 clients using olanzapine (Hough, 2001). Group designs have also generally demonstrated improvements using atypical antipsychotics. In an uncontrolled clozapine study with blind raters, Frankenburg and Zanarini (1993) found that there were global improvements in functioning and decreases in psychopathology. Chengappa, Ebeling, Kang, Levine, and Parepally (1999) used clozapine with 7 female inpatients and found decreases in self-mutilation, seclusion, use of as-needed anxiolytics, and injuries to staff and peers; in addition, global functioning ratings increased substantially. Another clozapine study investigated 12 borderline PD inpatients with severe psychotic symptoms; there were decreases in overall psychiatric symptoms and depression and improved global functioning (Bendetti, Sforzird, Colombo, Marrei, & Smeraldi, 1998). Parker (cited in Markovitz, 2004) treated 8 severe borderline PD patients using clozapine; hospitalizations were substantially reduced, leading to over $36,000 in reduced hospital costs per patient on average. Using risperidone with 15 borderline PD patients, Roca et al. (cited in Markovitz, 2004) demonstrated a reduction in impulsive aggression and a 13-point improvement on the Global Assessment of Functioning. An 8-week study of 9 patients with olanzapine demonstrated statistically significant improvements in many areas, including psychoticism, depression, interpersonal sensitivity, anger, global functioning, and overall symptomatology (Schulz, Camlin, Berry, & Jesberger, 1999). Bogenschutz and Numberg (2004) completed a randomized clinical trial of olanzapine. Forty participants were evenly divided between the drug and placebo conditions. Relative to the placebo condition, the olanzapine group demonstrated improvements on borderline PD symptoms and clinical global impression; weight gain was noted as a side effect. Zanarini and Frankenburg (cited in Markovitz, 2004) completed a double-blind, placebocontrolled study of olanzapine with 28 nondepressed women with borderline PD. Nineteen were assigned to the drug condition, and 9 were controls. The researchers found decreases in global symptoms and improvements in global functioning. On the basis of his review of the literature, Markovitz (2004) concluded, "There is a growing body of evidence to support the efficacy of the atypical antipsychotics in decreasing impulsivity, aggresBORDERLINE PERSONALITY DISORDER

141

sion, self-injurious behavior, and affective instability in [borderline PD]" (p. 93). Soloff (2000) recommended conceptualizing the individual with borderline PD as having difficulties that lie along four dimensions: cognitiveperceptual problems, affective dysregulation, impulsive-behavioral dyscontrol, and interpersonal psychopathology. Soloff constructed an algorithm of treatment recommendations on the basis of his comprehensive review of the literature. Cognitive-perceptual disturbances such as suspiciousness, paranoia, and thought disorder are treated primarily with low-dose neuroleptics, switching to an atypical neuroleptic if the former has inadequate efficacy and adding an SSRI or monoamine oxidase inhibitor for affective symptoms. For affective dysregulation, including depression, anger, anxiety, and lability, an SSRI is the first line of treatment; a low-dose neuroleptic can be added for anger, and clonazepam for anxiety. If these are insufficiently effective, other medications to try include valproate, lithium, or carbamazepine. Impulsive aggression, including bingeing and self-injurious behavior, is also primarily treated with SSRIs, followed by lithium, monoamine oxidase inhibitors, valproate, and carbamazepine, depending on the exact symptoms and response. The use of SSRIs for affective dysregulation and impulsivity was based on the theoretical work (presented above) on serotonergic insufficiency in people with borderline PD and other affective-behavioral dysregulation problems. Interpersonal psychopathology (problems in interpersonal relationships) is not directly treated with medications (except as it is impacted by the other three dimensions) and falls within the domain of psychotherapy (Soloff, 1998). Others who reviewed the literature reached similar conclusions (Coccaro, 1998; Hirschfeld, 1997). It should be noted that two studies have investigated the use of essential fatty acids as a form of treatment. Zanarini and Frankenberg (2003) did an 8-week double-blind randomized trial of ethyl-eicosapentaenoic acid versus placebo with 30 women with borderline PD. They found that the supplements decreased aggression and depression. A randomized controlled trial of essential fatty acids plus a vitamin and mineral supplement with 231 incarcerated young adults demonstrated that those in the active treatment group were approximately 26% less likely to be reported for antisocial behavior and had fewer rule violations than those in the placebo condition (Gesch, Hammond, Hampson, Eves, & Crowder, 2002). These nutritional supplements are extremely low risk compared with medications and have had promising results; further investigation is warranted. Although dramatic case studies are encouraging, it is not clear that the newer medications lead to improvements that are, on average, much better than those obtained with older medications. For example, Global Assessment Scale scores in Frankenburg and Zanarini's (1993) study of clozapine yielded approximately a 12-point improvement (from 31 to 43), which is similar to Soloff et al.'s (1989) 14-point improvement in their haloperidol 142

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

group (from 41 to 55). Enough studies are available that meta-analysis should be considered to evaluate the costs and benefits of various treatments. All of the findings should be interpreted with caution: Medication studies of individuals with borderline PD are marked by high dropout rates, and large placebo effects are also often seen in controlled studies. Most of the studies reviewed are small and uncontrolled; even in this best-studied of PDs, the research on medications is woefully inadequate. Adequately sized randomized clinical trials should be conducted on each medication used with this group. Researchers and clinicians should be sobered by paradoxical findings with widely used medications: Individuals with borderline PD may not have the expected improvements and may even get worse with particular drugs. Psychological Factors Millon's Theory Borderline PD, in Millon's conceptualization, is a "dysfunctional," or extreme, variant of dependent, histrionic, and passive—aggressive PDs. As such, the etiology, including biological underpinnings and psychosocial experiences, is related to the subtype. The more dependent types generally have more sluggish temperaments and a history of being overnurtured (with the inevitable meta-message that the child is incompetent and requires care). The more histrionic types have highly active temperaments and were reinforced for performing for their parents and others. The passive-aggressive (negativistic) types tend to have moody, irascible temperaments and were raised with parental inconsistency. In all cases, repeated failures of their attempts to cope with the world have led to increasing desperation. Rather than flexibly adapting to the environment, however, the person with incipient borderline PD tends to recycle the same coping efforts but at a higher or more extreme level of intensity. Eventually, the individual engages in extreme behaviors much of the time. Overall, Millon viewed mundane, oftrepeated patterns in the environment (such as ongoing parental inconsistency) as more central to the development of PDs than dramatic but time-limited traumatic events (such as a single episode of sexual abuse). The fundamental feature, as seen in Millon's tridimensional model, is that there is ambivalence on all three dimensions (active-passive, painpleasure, and self—other), which emerges as a near-constant state of ambivalence and tension. This is not true of all people with PDs. The person with dependent PD can feel comfortable in an environment in which he is consistently nurtured and supported; similarly, the individual with narcissistic PD can feel comfortable if interacting with one or more admirers. Not so with borderline PD. A persistently nurturing other person will tend to elicit fears of engulfment; however, anything less than complete devotion at every moment elicits abandonment terror. Similarly, the person with borderline PD tends to alternate between passively hoping for attention and affection from BORDERLINE PERSONALITY DISORDER

J 43

others and actively seeking to have his or her emotional needs met. Millon (1996) described this polarity conflict as signifying "the intense ambivalence and inconsistency that characterizes the borderline, their emotional vacillation, their behavioral unpredictability, as well as the inconsistency they manifest in their feelings and thoughts about others" (p. 660). The description of borderline PD in terms of Millon's eight domains is given in Appendix B. Of these domains, paradoxical interpersonal conduct, uncertain self-image, and split morphologic organization are most central and salient (Millon, 1999, p. 645). Psychodynamic Therapy

Psychodynamic formulations of borderline PD focus on a variety of developmental and constitutional factors that interact to form the disorder. The term borderline is derived from the conceptualization of Stern (1938) that there is a group of clients who seem to dwell at the boundary—the "borderline"—between psychosis and neurosis. It is important to note that Stern's initial interest in this area stemmed from the fact that there were people who seemed like they should be amenable to analysis who in fact did very poorly. Comparing psychoanalytic treatment with a necessary surgery, Stern stated, "A negative therapeutic reaction is nevertheless inevitable; in some, the reaction is extremely unfavorable, and, cumulatively, may become dangerous; patients may develop depression, suicidal ideas, or make suicide attempts" (Stem, 1986, p. 59). The word inevitable is chilling in this context; classical psychoanalysis is not recommended for this population. However, with some modest modifications from psychoanalysis, psychodynamic methods are effective. The theories described below draw primarily on object relations theory. Thus, the key issue is not the relationships with real people, such as the mother, but rather the individual's internal representation of the mother and, perhaps even more germanely, the relationship of various parts of the self (part'Self) to various parts of the other (part-objects). Thus, for example, the person with borderline PD may see him- or herself as a denigrated, abused self in relation to a sadistic, abusive other; both this self and this other are really part-self and part-object relations. O. F. Kernberg and colleagues used the concept of "borderline personality organization" rather than borderline PD (Clarkin, Yeomans, & Kemberg, 1999; O. F. Kemberg, 1967/1986a; O. F. Kemberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Borderline personality organization is conceptualized as a level of functioning rather than a categorical conception. Theoretically derived from the interplay of psychodynamic processes related to how the developing child handles an excess of aggressive libidinal energy, borderline personality organization includes features of not only borderline but also narcissistic, schizoid, schizotypal, paranoid, histrionic, antisocial, and dependent PDs (Clarkin et al., 1999; O. F. Kernberg, 1967/1986a). Excess aggres144

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

sion can be caused by constitutional factors or by childhood frustration. The individual then defends against the aggressive impulses using splitting and related defenses. Splitting occurs in normal development as a way of experiencing the positive and negative aspects of significant others in the environment. Newborns coo in the presence of a warm, loving mother and wail when the mother is unable to immediately provide for their needs. In normal development, children at some point integrate whole views of others, so they recognize that the father who is nurturing at one time is still the same person as the one who is withholding at another. However, when children have a massive excess of aggressive libidinal energy, good internalized objects are at risk of being completely overwhelmed by negative object representations. In other words, if one were to see the other person, say the mother, as a whole, she would be invested with a massive amount of hostile, aggressive energy and a relatively small amount of loving, nurturing energy and hence would be seen as essentially all bad. Splitting, then, protects the fragile internalized good objects from being overwhelmed by the aggressive, malevolent bad object representations. Splitting, being the primary defensive operation to cope with excess aggression, elicits several other defensive maneuvers. Primitive idealization, one side of splitting, occurs when external objects are seen as all good. Omnipotent control is overvaluation of the self and is related to devaluation, which is deflation of others. As seen in chapter 3, this volume, on paranoid PD, projective identification is a three-part process: (a) projection of an unacceptable impulse onto another while continuing to experience the impulse; (b) viewing the individual onto whom the impulse is projected as under the sway of the projected impulse, and thus frightening; and (c) attempts to control the person, often in a way that provokes the feared behavior. An example of projective identification is the client who repeatedly and with thinly veiled hostility accuses the therapist of being angry with her; eventually, the therapist does in fact become irritated and angry, "confirming" the client's suspicions. Denial, according to Kernberg (see Yeomans, Clarkin, &. Kernberg, 2002), is not so much denial of the existence of a perception, thought, or feeling but rather the splitting off of the emotion so that the phenomenon is seen as emotionally irrelevant. Kernberg (see Yeomans et al., 2002) recommended the traditional analytic techniques of clarification, confrontation, interpretation, and technical neutrality (placing oneself equidistant from the id, ego, and superego in helping the client to resolve conflicts). The sine qua non of his treatment, however, is analysis of the transference in the here and now; in fact, he recently labeled his therapy transference focused psychotherapy, Transference focused psychotherapy has been manualized to promote consistent use in different settings (Yeomans et al., 2002). Masterson (1981) had a different perspective. Rather than emphasizing the child's internalized aggression, he saw the primary problem as the mother's BORDERLINE PERSONALITY DISORDER

145

"libidinal withdrawal" from the child, frustrating the child's separationindividuation process. The most common pattern occurs when the mother discourages separation, instead encouraging dependency and clinging. The mother, according to Masterson, is generally a person with borderline PD herself who has her own problems with separation anxiety. The child's attempts to individuate provoke extreme anxiety in the mother, which in turn elicits caretaking behavior from the child. Another pattern is for the child to regress and cling to the mother, failing to individuate, thus gratifying the mother's emotional needs. Alternatively, the mother may withdraw, unable to handle the child's dependency needs. For Masterson, like Kemberg, the key to understanding the individual with borderline PD was understanding the part-self and part-object relations that compose the psyche. The mother is divided into two part-objects as a function of splitting. There is the rewarding object relations unit, which is the all-good object, and the withdrawing object relations unit, which is all bad (hostile, withdrawing, and rejecting). The child can defend against feelings of abandonment in one of two ways. The first way is to project the rewarding unit onto others (including the therapist) while internalizing the withdrawing unit. This leads to clinging subordination. The second path is to project the withdrawing unit onto others while the rewarding unit is internalized. Others are thus seen as hostile, critical, and distancing. The client avoids thoughts and feelings that interfere with this defense, primarily through denial, and psychotherapeutic progress once again grinds to a halt. Abandonment depression, and the defenses built around it, for Masterson, constitute the heart of borderline psychopathology. Masterson called this pattern the "borderline triad: separation-individuation leads to depression which leads to defense" (Masterson, 1981, p. 133). Like Kernberg, Masterson recommended confrontation as the path through which to break this stalemate. The purpose of the confrontation is to "render the functioning of the split object relations unit/pathologic ego alliance ego alien" (p. 136). That is, clients must experience their perceptions of others as partobjects (e.g., as entirely hostile, withdrawing, bad, or good), as something foreign and in need of repair rather than as a necessary and adaptive response to reality. Stated Masterson, "The clinging transference calls for the confrontation of the denial of destructive behavior . . . while the distancing transference calls for the confrontation of the negative, hostile projections, usually on the therapist" (1981, p. 137). Confrontation, when effective, thus increases anxiety, because clients become aware of conflicts that were formerly suppressed, denied, or defended against through acting out. When they recognize that these defenses are selfdestructive, they control their behavior, thus experiencing the abandonment depression. This promotes a healing cycle: "There results a circular process, sequentially including resistance, confrontation, working through the feel146

PERSONALITY-G VIDEO THERAPY FOR DEPRESS/ON

ings of abandonment (withdrawing part unit), further resistance (rewarding part unit) and further confrontation, which leads in turn to further working through" (Masterson, 1981, p. 137). According to Masterson, borderline clients do not have transference in the classical sense, because transference requires whole-object relations. Instead, they engage in transference acting out. The concept is similar to Freud's repetition compulsion, in which events are repeated not in memory but in behavior. Just as the resolution to the repetition compulsion is interpretation, which releases repressed memories, the resolution to transference acting out is confrontation in the transference, which brings awareness of the meaning of the behavior. This allows the client to increasingly perceive the therapist as a whole object, which permits working through. As Masterson stated, "The more he invests in the therapist as a real object, the more he turns to therapy to work through his feelings of abandonment rather than to the rewarding unit/pathologic ego alliance to relieve them" (1981, p. 151). Masterson's and Kernberg's conceptualizations are similar in a number of ways, especially in the area of technique. Both emphasize confrontation, especially confrontation of the transference, as the path to resolution of borderline psychopathology. Both use rather traditional psychoanalytic techniques (e.g., technical neutrality). The main differences are their etiological assumptions, with Kernberg emphasizing excess aggression and Masterson emphasizing maternal unavailability. Cognitive-Behavioral Conceptualization and Interventions Cognitive-behavioral therapy for borderline PD is built primarily on the notion that people who have the disorder are prone to a variety of beliefs that are then logically related to their emotions. The acquisition of these beliefs and behaviors is generally thought to follow the principles of social learning (e.g., Bandura, 1977), reinforcement (e.g., Skinner, 1953), and associational learning (e.g., Pavlov, 1963). The relationship that is encouraged between client and therapist is that of teacher and student who engage in "collaborative empiricism" to shine the light of reason on the client's potentially irrational beliefs. Young's (1987) work with schemas, originally labeled "schema-focused cognitive therapy" (see also A. T. Beck & Freeman, 1990) and now known as "schema therapy" (Young, Klosko, & Weishaar, 2003) examines typical beliefs held by people with PDs, including borderline PD. Young explicated typical beliefs that persist in people with borderline PD. By educating clients about schemas, the therapist can align with the client against the maladaptive schema. Examples of schemas that typify borderline PD are listed in Exhibit 7.1. Beck and his associates (A. T. Beck & Freeman, 1990; A. T. Beck, Freeman, & Davis, 2004) have argued that dichotomous (all-or-none) thinking plays an important role in borderline PD pathology. The phenomenoBORDERLINE PERSONALITY DISORDER

147

EXHIBIT 7.1 Maladaptive Ways of Thinking Learned in Early Childhood by People With Borderline Personality Disorder Early maladaptive schemas Abandonment/instability Mistrust/abuse Emotional deprivation Defectiveness/shame Dependence/incompetence Undeveloped self Insufficient self-control/selfdiscipline Subjugation Punitiveness

Possible expression I worry that people I feel close to will leave or abandon me. I have been physically, emotionally, or sexually abused by important people in my life. Most of the time, I haven't had someone to nurture me, share himself or herself with me, or care deeply about everything that happens to me. I am unworthy of the love, attention, and respect of others. I do not feel capable of getting by on my own in everyday life. I feel that I do not really know who I am or what I want. I often do things impulsively that I later regret. I feel that I have no choice but to give in to other people's wishes, or else they will retaliate or reject me in some way. I'm a bad person who deserves to be punished.

Note. Based on the Young Schema Therapy Questionnaire, Short Form and Long Form, adapted from Cognitive Therapy for Personality Disorders: A Schema-Focused Approach (3rd ed., pp. 12-16), by J. E. Young, 1999, Sarasota, FL: Sarasota Professional Resource Press, and personal communication from the author, May 3, 2002. Reprinted by permission of Jeffrey E. Young. Reproduction without written consent of the author is prohibited.

logical parallel of the psychodynamic construct of splitting, all-or-none thinking is seen as having broad-reaching implications: Since dichotomous thinking can produce extreme emotional responses and actions and can produce abrupt shifts from one extreme mood to another, it could be responsible to a considerable extent for the abrupt mood swings and dramatic shifts in behavior that are a hallmark of BPD. (A. T. Beck & Freeman, 1990, p. 187) A. T. Beck and Freeman (1990) further noted that relationship issues with the therapist will be much more prominent for people with borderline PD than for those with other disorders. A. T. Beck et al. (2004) recommended some specific strategies for fostering a relationship with the person with borderline PD: The therapist actively breaks through the detachment of the patient, is actively involved in crises, soothes the patient when sad, and brings in him- or herself as a person. . . . This approach almost necessarily provokes difficult feelings in the patient, based on core schemas, which is good because these can be subsequently be addressed in therapy. Thus, this "reparenting" approach is considered an essential ingredient of the treatment, (p. 202) 148

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

People with borderline PD are also likely to have intense emotional reactions that appear to be highly inappropriate to the situation. The structured, task-focused nature of cognitive-behavioral therapy tends to minimize what analysts would call "transference" with most clients; however, individuals with borderline PD are likely to have strong emotional reactions that are not a direct function of the therapist's behavior. From a cognitivebehavioral perspective, transference can be viewed as stimulus generalization from a previous relationship to the current one, or, as A. T. Beck and Freeman (1990) rioted, applying previously held general beliefs rather than responding to the therapist as an individual. The therapist must be prepared to help the client to unpack the meaning of these intense reactions based on prior experiences and strongly held beliefs. Other aspects of borderline pathology also interfere with the development of a productive cognitive-behavioral therapeutic relationship. Identity confusion interferes with setting goals, because the individual often experiences rapidly shifting agendas. The fear of intimacy can provoke discomfort, premature termination, or acting out even with the modest intimacy typically seen in cognitive-behavioral therapy. Fear of and anticipation of rejection can lead to premature termination. The establishment and continued maintenance of a positive therapeutic relationship provides the context in which the client can be provided with skills training in particular areas of deficit (such as assertiveness and other relationship skills) and encouraged to engage in behavioral experiments. The goal is to persistently identify the client's beliefs, particularly those that may be distorted or irrational, and challenge these beliefs against reality. Dialectical Behavior Therapy Theory

Perhaps it is fitting, given the paradoxical nature of borderline PD, that a treatment developed specifically to address it is, in its essence, designed to address paradox. According to Linehan (1993), dialectical behavior therapy is so named because Linehan saw the principal issues involved in borderline PD as the resolution of diametrically conflicting tendencies (thesis and diathesis) that must be brought to resolution (synthesis). Drawing on Zen Buddhism, Linehan viewed the synthesis as transcending the rational, similar to a Zen koan (paradox). The resolution to the polarities, rather than a rational solution, is an experience. The prototypical dilemmas are explained below. The Invalidating Environment. Before attending to the polarities underlying Linehan's model, it is important to address critical developmental precursors to borderline PD. One, according to Linehan (1993), is the "invalidating environment." Invalidation indicates that significant others are sending messages that one's feelings, thoughts, and perceptions are not real or do not matter. Such invalidation, according to Linehan, can contribute to the development of borderline PD. Examples include the girl whose interests in mechanical pursuits do not fit society's gender stereotyping and who is BORDERLINE PERSONALITY DISORDER

149

punished or told her interests are bad or wrong; conversely, the boy who is told he should be able to control his emotions and that his yearning for nurturance is a show of weakness is also being invalidated. Consistent invalidation leads to confusion and poor self-esteem. As is emphasized below, borderline PD results when the biologically vulnerable individual is raised in a persistently invalidating environment. The concept of invalidation explains the finding that sexual abuse is common among people with borderline PD. Sexual abuse is the ultimate invalidation. The victim's well-being is irrelevant to the abuser, who is gratifying his or her needs. As described by Linehan (1993), Sexual abuse, as it occurs in our culture, is perhaps one of the clearest examples of extreme invalidation during childhood. In the typical case scenario of sexual abuse, the person being abused is told that the molestation or intercourse is "OK," but that she [or he] must not tell anyone else. The abuse is seldom acknowledged by other family members, and if the child reports the abuse she [or he] risks being disbelieved or blamed, (pp. 53-54) Emotional Vulnerability Versus Self-Invalidation. Returning to the polarity model, Linehan (1993)defined emotional vulnerability as ongoing and extreme emotional sensitivity, intense emotional reactions, and the experience of persistent negative emotional reactions. She compared this with the physical hypersensitivity of the burn patient: The net effect of these emotional difficulties is that borderline individuals are the psychological equivalent of third-degree burn patient. They simply have, so to speak, no emotional skin. Even the slightest touch or movements can create immense suffering. Yet, on the other hand, life is movement. Therapy, at its best, requires both movement and touch. Thus, both the therapist and the process of therapy itself cannot fail to cause intensely painful emotional experiences for the borderline patient.... it is the experience of their own vulnerability that sometimes leads borderline individuals to extreme behaviors (including suicidal behaviors), both to try to take care of themselves and to alert the environment to take better care of them. (p. 69) Linehan believed that emotional vulnerability is the core feature of borderline PD, with many of the other symptoms making sense as an attempt to cope with it. Excessive emotional arousal, such as feelings of depression, interferes with cognitive functioning and behavioral responses that would facilitate coping. Attempts to regulate painful emotions are the precursors of impulsive behaviors, such as drug or alcohol use and unprotected sex, which then lead to further problems. Attempts to modulate emotions through social interactions can lead to excessive dependency and concomitant fears of abandonment. Thus, emotional vulnerability becomes a focal point around which many borderline symptoms make sense. This tendency toward affective 150

PERSONAllTY-G U1DED THERAPY FOR DEPRESS/ON

dysregulation is largely biological, whereas its counterpart, self-invalidation, is predominately learned. Self-invalidation indicates a tendency on the part of the individual to respond with shame, guilt, and intropunitiveness to environmental stimuli. Often, self-invalidation leads to depression. The combination of emotional vulnerability and self-invalidation leads to a vicious circle for clients. Unable to internally regulate their emotions, they turn to others to help stabilize their emotions. However, the extreme emotions of the person with borderline PD are beyond the empathic scope of the typical friend and even of many therapists. Isn't it natural enough, for example, if the individual is literally suicidal over a breakup with a lover of a few months, to say, "C'mon, now, pull yourself together, there are lots offish in the sea," and so on? When the individual repeatedly fails to respond to typical reassurances, others often get burnt out; frustrated; and, ultimately, rejecting. This pattern, noted in depression under the rubric of "excessive reassurance seeking" (see chap. 3, this volume), is exacerbated in the case of the person with borderline PD, who finds such responses powerfully invalidating. Although the helper may be attempting to convey the message, "You're fine, you just need some perspective," the message received is, "My feelings don't count, my reality is not real to you, you don't understand how bad I feel." The person with borderline PD may then make an extreme gesture, such as a suicide attempt, out of desperation ("I feel terrible and no one can help me") or in an effort to prove the severity of his or her despair ("You didn't think 1 was desperate, but I really was"). Thus, attempts to regulate emotions generally lead to further invalidation. The dialectical dilemma for clients, then, given their tendency toward black-and-white thinking, is to vacillate between recognizing their emotional vulnerability (thereby blaming others for their lack of understanding) or believing the messages from the invalidating environment ("You are fine, you just need to pull yourself together") and feeling guilty, shameful, and inadequate. Simultaneously, the therapist finds that it is difficult to avoid invalidating the patient. Linehan (1993) gave a number of examples: Common instances of invalidation include the therapist's offering or insisting on an interpretation of behavior that is not shared by the patient; setting firm expectations for performance over what the patient can (or believes she can) accomplish; treating the patient as less competent than she actually is; failing to give the patient the help that would be given if the therapist believed the patient's current perspective to be valid; criticizing or otherwise punishing the patient's behaviors; ignoring important communications or actions of the patient; and so on. Suffice it to say that in most therapy relationships (even good ones) a fair amount of invalidation is common, (p. 76)

Predictably—though uncomfortably, for the therapist—the patient responds to the invalidating (therapy) environment with anger, depression, BORDERLINE PERSONALITY DISORDER

151

anxiety, or avoidance (including suicide attempts or dropping out of therapy). The patient can feel invalidated whether the therapist is aiming for change or for acceptance: In reviewing how a particular interaction went wrong or why some goal was not reached, if the therapist in any way implies that the patient could improve performance the next time, the patient is likely to respond that the therapist must be assuming that the patient has been wrong all along and that the invalidating environment is right.... On the other hand, if the therapist uses a non-change oriented tactic—listening to the patient or sympathetically validating the patient's responses—then the patient is likely to panic at the prospect that life will never improve. (Linehan, 1993, p. 77)

To resolve these dilemmas, the patient must learn self-acceptance, compassion, and self-soothing and accept gradual change, and the therapist must be keenly attuned to messages regarding invalidation and rapidly shift between validation and change strategies. Active Passivity Versus Apparent Competence. Active passivity is Linehan's eye-catching phrase that captures the phenomenon of demanding clinginess and neediness seen in people with borderline PD. It is something of a hybrid between the passivity of the dependent, who waits and hopes for support, and the activity of the histrionic, who provides entertainment in "exchange" for nurturance. The likely experiential history of people experiencing active passivity is a history of failure when they attempt to cope actively with situations (i.e., learned helplessness), presumably accompanied by at least some instances of soothing by others. Biologically hypersensitive individuals who lack the capacity to self-soothe, are unable to tolerate their current distress, and have a history of failing when they make active efforts to cope may desperately turn to others to rescue them. According to Linehan (1993), "A passive self-regulation style is probably a result of the individual's temperamental disposition as well as the individual's history of failing in attempts to control both negative affects and associated maladaptive behavior" (p. 79). Gender roles also contribute in that women tend to learn to use emotion-focused coping and see the "self in relationship" (Gilligan, 1988) within the context of a patriarchal culture. To the extent that people see rescue by other individuals as the only way to manage their lives, they will tend to experience frantic fear of abandonment. Apparent competence refers to the behavior of a person who is competent in some areas while behaving completely inappropriately at times. The individual's competence, for example, at work, may belie substantial deficits in other areas. Others are surprised, perhaps even shocked, when a person who appears to be a typical colleague suddenly has a "meltdown" or behaves inappropriately for no apparent reason. Linehan (1993) explained this phenomenon as occurring because of (a) a lack of stimulus generalization, (b) a failure on the part of the person with borderline PD to communicate his or 15 2

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

her vulnerability clearly because he or she has learned to inhibit emotional expression as a form of coping, and (c) variations in competence based on perceived support (when people with borderline PD are with a supportive individual, or believe they are in a secure, supportive relationship, they do relatively well—which means that they will function deceptively well during therapy sessions). A leading advocate for people with borderline PD shared a story that illustrated the phenomenon of apparent competence perfectly. She was in her office, where a woman with borderline PD, who happened to be a physician, was raging at her. In the midst of the outburst, the physician's pager went off. She calmly went to the phone, called the hospital, and gave advice and a prescription for her patient. She then hung up the phone and resumed her tirade (V. Porr, personal communication, May, 28, 2003). Certainly, one could understand why many observers would conclude that the rage was not real or was put on for effect. However, according to Linehan's theory, such an interpretation would be in most cases both inaccurate and harmful. Rather, the individual with borderline PD exhibited apparent competence—the skills she had acquired to remain calm and cool in her role as physician did not: generalize to her interpersonal role with the advocate. In fact, she was in a state of substantial emotional dysregulation. Unfortunately, then, this apparent competence leads to a vicious circle, in which incompetence is seen by others as a lack of effort, "playing games," or manipulation; because this interpretation is different from the client's viewpoint, it perpetuates the invalidating environment. The dialectical dilemma for clients on this polarity is that to the extent they have difficulty regulating their own emotions and thus rely on others, the more ashamed they feel, because of our independence-oriented, dependency-shunning culture. Therefore, individuals attempt to inhibit their emotional responses, thus perpetuating the myth that they are able to regulate their emotions just like anyone else. When they inevitably fail to control their emotions, they swing from guilt (because they failed) to anger (because others do not understand). In either case, emotional dysregulation ensues, including extreme attempts at regulation (such as suicide attempts). The dialectical dilemma for therapists is that if they see only the client's competence, they will invalidate his or her true skill deficits. Further, by aligning themselves with the apparent competence they risk attributing failures to "resistance," which can undermine the therapeutic relationship. Alternatively, if the therapist aligns excessively with the active passivity—which is easy enough to clo by simply empathizing with the client—then the client will not optimally improve; the therapy may even become paralyzed. The best solution is to flexibly alternate support and challenge, going back and forth, in many cases, within a single session. Unrelenting Crisis Versus Inhibited Grieving. People with borderline PD tend to go from one crisis to the next. Linehan (1993) explained this as being caused by a combination of low stress tolerance and poor coping skills. BORDERLINE PERSONALITY DISORDER

J 53

An initial problem may leave the person feeling overwhelmed; he or she then is unable to resolve the problem sufficiently. This emotional state makes further problems more overwhelming, leading to yet another crisis. This process becomes a vicious circle of unending crisis and feelings of desperation. Inhibited grieving "refers to a pattern of repetitive, significant trauma and loss, together with an inability to fully experience and personally integrate or resolve these events" (Linehan, 1993, p. 89). Studies show that approximately two thirds to three quarters of people with borderline PD have a history of being abused sexually; thus, a majority of people with borderline PD are coping with trauma-related symptoms (Linehan, 1993, pp. 52-53). The problem, as Linehan saw it, is that these individuals are unable to regulate their emotions well enough to handle normal grieving; if they were to process the loss they would "fall apart." The person with borderline PD fears processing emotions that were so overwhelming that he or she would become dysfunctional (e.g., curl up in a fetal position for hours)—and has, most likely, experienced such emotions. Therefore, like many people with posttraumatic stress disorder, the individual avoids contact with any reminders of the stressors, both external and internal. This strategy is only partially successful, because reminders are common in the environment (especially in interpersonal relationships), and mental representations based on the traumatic events influence many aspects of the person's life. What unfolds, then, is a chronic, partial grieving, with frequent emotional dysregulation. I recently supervised an evaluation of a case in which a client with borderline PD and a history of severe physical abuse (e.g., broken bones) described her experience with psychodrama treatment. As she relived and reexperienced her past, she became so anxious that she felt persistent panic and feelings of desperation. The ensuing panic disorder created significant disruptions in her functioning and required a variety of psychological and pharmacological interventions. Thus, in working through a traumatic past, the person with borderline PD may require substantial support to avoid an intolerable worsening of symptoms. The dialectical dilemma for clients is that they cannot avoid exposure to loss and trauma cues because there are too many (e.g., aspects of many relationships are partial reminders of abuse experiences). Further, they cannot inhibit their grief reactions indefinitely as they go from crisis to crisis. Their efforts to escape feelings of emptiness and desperation, such as drinking, speeding, unprotected sex, and so on, provoke further crises. Their coping strategies lead to a vicious circle of mood swings and impulsive behavior. The dialectical dilemma for the therapist, on the other hand, is, as noted by Linehan (1993), to balance his or her response to the oscillating nature of the patient's distress—sometimes expressed as acute crisis and overwhelming affect, and at other times presented as complete inhibition of affective responding. An intense reaction by the therapist at either extreme may be all that is needed to push the patient to the other extreme, (p. 93) 154

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

To do so, the therapist is advised to help clients to process their grief, and encourage them to know that they can survive the inherent stress of doing so, while providing concrete grieving strategies or skills. Simultaneously, or in rapid alternation, the therapist must validate the client's persistent sense of crisis. Client-Centered, Humanistic, and Existential Therapies An important theoretical perspective within the client-centered and humanistic therapy domain is Margaret Warner's (2000) "fragile process." Given the antilabeling orientation of most humanistically oriented therapists, it is relatively difficult to find theoretical work on PDs from that perspective. However, assuming that Linehan's (1993) theory about the invalidating environment is correct, it is likely that a therapeutic approach based on validation and unconditional positive regard would be effective; the one outcome study I could find (Eckert & Wuchner, 1996) indicated results comparable to those of dialectical behavior therapy (Linehan, 1993) and transference-focused therapy (Clarkin et al, 1999). Warner defined fragile process as follows: "Fragile" process is a style of process in which clients have difficulty modulating the intensity of core experiences, beginning or ending emotional reactions when socially expected, or taking the points of view of other people without breaking contact with their own experience. Clients in the middle of a fragile process often feel particularly high levels of shame and self-criticism about their experience. (Warner, 2000, p. 145) Integrating fragile process with developmental theory, especially attachment theory, Warner (2000) hypothesized that individuals who are prone to fragile process are insecurely attached. Individuals with insecure attachment to adult figures find that high arousal leads to emotional overload and disorganization, which neither they nor their caregivers are able to soothe. As children they would thus often feel either fearful (because they could not be soothed) or angry (if they expected the caregiver to help and were disappointed or frustrated). As infants they would either constantly seek out attachments to find sustaining nurturance or self-protectively withdraw from others. The dilemma throughout life, then, is that if persons with fragile process (like persons with borderline PD) express their feelings, they are often misunderstood; if they withdraw, they feel empty. As Warner (2000) put it, Clients who have a fragile style of processing often experience their lives as chaotic or empty. If clients with high-intensity fragile process choose to stay connected with their experience in personal relationships, they are likely to feel violated and misunderstood a great deal of the time. When they express their feelings, others in their lives are likely to see them as unreasonably angry, touchy, and stubborn. These others are likely BORDERLINE PERSONALITY DISORDER

155

to become angry and rejecting in return, reinforcing clients' sense that there is something fundamentally poisonous about their existence. Clients who continue to express their feelings are likely to have ongoing volatile relationships or a succession of relationships that start out well and then go sour. If, on the other hand, they give up on connecting or expressing their personal reactions they are likely to feel frozen or dead inside. Many alternate, holding in their reactions while feeling increasingly uncomfortable and then exploding with rage at those around them, (p- 152)

Warner (2000) noted that there are pitfalls for the therapist treating people with fragile process: The client may be able to talk about feelings of rage at the therapist and very much want them understood and affirmed. Yet, therapist comments to explain the situation or disagree with the client will be felt as attempts by the therapist to annihilate his experience, (p. 150)

So what is the proper intervention for persons with fragile process? Warner (2000) stressed that it is essential to try to understand them from their own perspective. One error that therapists frequently make with people in general, and especially those with fragile process, is to assume that they have words for their feelings. Often, they do not. People with fragile process often act out their feelings (e.g., by taking drugs, self-mutilating, or attempting suicide). If clients are struggling for words, therapists need to support them through it and avoid the temptation to guess or hypothesize about their feelings. A comment such as "something about that feels uncomfortable, but you're not quite clear what it is" is often effective and will allow the person with fragile process to continue to explore his or her experience (Warner, 2000, p. 153). If the therapist fills the space by putting words into the person's mouth, the client will often feel misunderstood—this being the core problem for people with borderline PD.

COUNTERTRANSFERENCE Several theorists have indicated that countertransference responses to individuals with borderline PD tend to be similar because of the powerful pull of the disorder. (Gabbard & Wilkinson, 1994; O. F. Kernberg, 1975, 1967/1986a; O. F. Kernberg et al., 1989; Meissner, 1988). Therapists frequently respond with feelings of worthlessness, depression, guilt, anxiety, and self-doubt when, because of the client's splitting, the therapist is devalued and rejected; such devaluation can also, understandably, lead to anger, rage, and a desire by the therapist to terminate therapy (Adler, 1985; Gabbard 6k Wilkinson, 1994; O. F. Kernberg et al., 1989; Meissner, 1982). As will be discussed later in the chapter on narcissistic PD (chap. 9, this volume), such 156

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

feelings are generated as a function of therapists' narcissistic needs: Therapists are typically invested in being validated by clients' appreciation and by their progress in therapy. For similar reasons, when they cannot live up to their clients' magical expectations, therapists often feel frustrated, depleted, ashamed, and impotent and doubt their own competence (Adler, 1985; O. F. Kernberg, 1975; Meissner, 1982, 1988). Therapists may experience rescue fantasies or engage in rescuing behaviors in which the therapist gives the client increasing amounts of time and reassurance (Adler, 1985; Gabbard & Wilkinson, 1994). This is especially true with clients who are victims of sexual abuse. Gabbard and Wilkinson (1994) suggested that the rescuer role unfolds in a predictable pattern. Initially, therapists take extraordinary measures to show patients that they care and to try to undo parental harm. However, the needs of the client form a bottomless pit; eventually, the therapist begins to feel like a victim rather than a rescuer. The authors noted, "Clinicians who treat borderline patients with a history of sexual abuse must never forget that an abusive parent has been internalized and thus exists as an introject ready to be activated at the drop of a hat" (p. 55). The pattern can escalate further if therapists try to hide their irritation by redoubling their efforts to show that they care. Gabbard and Wilkinson suggested that the therapist break the cycle by frankly acknowledging his or her own limits. Cognitive therapists have noted that clients with borderline PD often distort therapists' statements. For example, through magnification, the client may see therapist suggestions aimed at increasing autonomy as threats of abandonment; through selective abstraction, the client may see only the negative in a therapeutic intervention. These cognitive distortions may lead to powerful feelings of frustration and hopelessness on the part of therapists. Clinicians may have thoughts such as, "There is nothing 1 can do to help this patient," and "1 must be tough and detached to prove I cannot be manipulated" (Layden, Newman, Freeman, & Morse, 1993, pp. 122-123). In addition to consultation, cognitive theorists have suggested the use of thought records3 for therapists to challenge their countertransference responses (A. T. Beck et al., 2004; Layden et al., 1993). Individuals with borderline PD may become explicitly or implicitly seductive, which can arouse sexual feelings in the therapist (Searles, 1986). Gabbard and Wilkinson (1994) cited several empirical studies that suggest that borderline PD is a risk factor for therapist sexual acting out. This issue is 'Dysfunctional thought records are a standard cognitive therapy technique that has only recently been suggested for self-care ot the therapist as well as for use with clients. The technique involves making columns labeled, for example, "situation," "emotion," "automatic thought," "rational response," and "outcome." In the situation in which a person with borderline PD threatens suicide, the therapist may feel angry and have the automatic thought, "She is trying to manipulate me." A rational response might be, "Whether or not she is trying to get me to do something using extreme measures, she is in emotional pain," which leads to lower anger and increased compassion.

BORDERLINE PERSONALITY DISORDER

15 7

especially powerful if the client is a victim of incest or sexual abuse. As noted above, abuse victims pull for powerful rescuer fantasies on the part of the therapist and for special treatment; in the context of multiple boundary transgressions, the risk of sexual acting out increases (Gabbard &. Wilkinson, 1994). Empirical research is fairly consistent with the clinical observations described above. The responses of therapists and therapists-in-training to video vignettes of individuals with borderline PD have indicated that the participants felt interested (curious, amused, fascinated) and angry (frustrated, irritated, exasperated), as well as "disconnected" and "sad" and experienced "compassion." Participants also mentioned "leaning back" body language. Herein we can see the ambivalence of therapists. The data can be interpreted in one of two ways: Either some therapists had positive feelings (interested, compassionate) and others had negative ones (angry, disconnected), or participants had mixed reactions to the highly variable presentations portrayed in the vignettes. Either way, the ambivalence is notable in the countertransference, even based on brief (5- to 10-minute) presentations (Bockian, 2002a; see chap. 1, this volume, for additional details of the study). An empirical study of 155 psychotherapists' (3-27 years of experience) reactions to an audiotaped interview with a client with major depression or borderline PD demonstrated that the clients with borderline PD were seen as more dominant and hostile, whereas individuals with major depression were perceived as more submissive and friendly; participants also saw individuals with major depression as being more likely to benefit from treatment and more likely to have a positive outcome. Brody and Farber (1996) studied 336 therapists' responses to written clinical vignettes of individuals with borderline PD, depression, and schizophrenia. Borderline PD was associated primarily with a negative countertransference, including feelings of irritation, frustration, and anger and lower ratings of liking the client in the vignette; on the positive side, consistent with the Bockian (2002a) study, therapists were as interested in the clients with borderline PD as they were in the clients with depression and schizophrenia. Holmqvist (2000) performed a study of 143 patients and 124 staff, generating 3,605 feeling checklists. Borderline personality organization (O. F. Kernberg, 1975), a construct related to borderline PD, was related to increased aggressive feelings and decreased relaxed feelings in staff. Thus the small but growing empirical literature is validating the clinical literature demonstrating that themes of hostility, irritation, anger, and frustration are important; further empirical work is needed to investigate themes such as boundary violations, rescuer fantasies and behaviors, helplessness, and hopelessness.

SOCIAL CONSIDERATIONS AND DIVERSITY Borderline PD appears to be increasing in frequency. This may be explained, in part, by clinicians' increasing awareness of Axis II disorders and 158

PERSONALITY-G U1DED THERAPY FOR DEPRESSION

the concomitant increase in diagnoses; however, there are also forces at work that are genuinely increasing the number of new cases. Because our genetics have not changed appreciably, social changes appear to be the most likely causal factors. One could say that if we were to design a society most likely to create borderline PD among its citizens, our current American society would be almost ideal. Millon (1987) outlined a series of social factors that have contributed to this increasing prevalence. We live in a world of rapid technological and sociological change, the pace of which is constantly accelerating. In our highly mobile society, it is becoming less likely that children will grow up in one stable environment, in one home, in one city, or even in one family. Formerly stable institutions such as religious institutions and marriage are no longer so stable. Participation in religious institutions is down (Clark, 2000; Hadaway & Marler, 1993; C. Smith, Denton, & Paris, 2002). More than 50% of marriages end in divorce, and second marriages have an even higher failure rate. The breakup of parents makes it more difficult for the developing child to internalize stable role models. Further, it is not uncommon for a divorcing couple to line up on opposite sides of a courtroom, with each side painting itself as all good and the other as all bad. The developing child can internalize this kind of real-life splitting. Many women with children are now engaged in full-time careers, but few fathers have chosen to stay home with their children. Today, children are often raised by a patchwork of "others," including day-care workers, babysitters, and aides working in early education programs. Extended kinship networks, although still a positive and stabilizing force in African American, Asian American, and Latino subcultures (Sue & Sue, 2003), have had a declining role in White majority culture. Working parents often come home relatively late, exhausted from workday demands. They have difficulty spending the few precious moments they have with their children providing firm, consistent discipline. Instead, they often assuage their guilt by being lax or lavishing the child with gifts. Television and other video media also have a profound impact on personality development. Role models and heroes have become increasingly violent, unstable, and outwardly sexual. Emotional shallowness and instability often dominate TV programs. Problems develop and are resolved in 30 to 60 minutes, often as a result of a dramatic 2-minute confrontation. The sincere expression of feelings and the negotiations that constitute real conflict resolution do not happen on TV. It is reasonable to theorize that as our children watch television they are learning how to be impulsive, cynical, sexually unrestrained, explosively angry, and melodramatic—that is, more borderline. According to Millon (1987), TV may be nothing but simple pablum for those with comfortably internalized models of real human relationships, but for those who possess a BORDERLINE PERSONALITY DISORDER

159

world of diffuse values and standards, or one in which parental precepts and norms have been discarded, the impact of these "substitute" prototypes is especially powerful, even idealized and romanticized. And what these characters and story plots present to vulnerable youngsters are the stuff of which successful half-hour "life stories" must be composed to capture the attention and hold the fascination of their audiences—violence, danger, agonizing dilemmas, and unpredictability, each expressed and resolved in an hour or less—precisely those features of social behavior and emotionality that come to characterize the affective and interpersonal instabilities of the [person with borderline PD]. (p. 365)

Another phenomenon pervading American culture that encourages the development of borderline personality behaviors is the "empty self." According to Cushman (1990), It is a self that seeks the experience of being continually filled up by consuming goods, calories, experiences, politicians, romantic partners and empathic therapists in an attempt to combat the growing alienation and fragmentation of its era. This response has been implicitly prescribed by a post-World War II economy that is dependent on the continual consumption of nonessential and quickly obsolete items and experiences, (pp. 600-601)

Alienated from family and community life, people experience emptiness, loneliness, and meaninglessness—foundations of the borderline personality. The answer promoted by powerful forces within our culture is to buy more to feel better. Of course, material items never really fill the void, so people continue to experience the emptiness and the drive to fill it. Explained Cushman (1990), the U.S. national character was once one that valued community; it is now a nation that values spending and consuming. Where it was once a society of creators, it is now a society of consumers, impulsive, cynical, depressed, and increasingly enraged by simply waiting—on the road, in line, and online. Finally, the increasing prevalence of sexual abuse (Sedlak & Broadhurst, 1996) is likely a contributing factor in the increasing prevalence of borderline PD. The causal role of sexual abuse in borderline PD is complex. We do know that not all individuals who have been sexually abused develop borderline PD, and not all people with borderline PD have been sexually abused. Zanarini et al. (1998) have shown that borderline PD cannot be reduced to complex posttraumatic stress disorder. Nonetheless, borderline symptoms logically relate to sexual abuse. In addition to Linehan's (1993) observations about the connection between invalidation and sexual abuse, those who have been sexually abused commonly use defenses that are also used by people with borderline PD. Dissociation (to mentally escape from the abuse) and splitting (to allow one to have a relationship with the abuser) are associated, respectively, with DSM-IV-TR's diagnostic Criteria 9 and 2 for borderline PD. Low self-esteem, a common concomitant of abuse, often leads to depen160

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

dency and fear of abandonment (Criterion 1), suicidal feelings (Criterion 5), and depression (Criterion 6). Thus, unless proven otherwise, it is wise to assume that sexual abuse plays a contributing role in borderline PD, and that as rates of abuse rise, so will rates of borderline PD. On the topic of sexual abuse, it is important to note that therapists may erroneously blame families or assume that family members were abusive when in fact the family members are often the greatest source of support to the person with borderline PD. Gunderson, Berkowitz, and Ruiz-Sancho (1997) put it this way: I [John Gunderson] was a contributor to the literature that led to the unfair vilification of the families and the largely unfortunate efforts at either excluding or inappropriately involving them in treatment. So it is with some embarrassment that I now find myself presenting a treatment that begins with the expectation that families of borderline individuals are important allies of the treaters and that largely finesses the whole issue of whether they had anything to do with the origins of psychopathology. . . . The parents generally saw the families as much healthier than did the borderline offspring. Much of the preceding literature about the families of borderline patients derived solely from reports provided by the borderline patients, and rarely included the families' perspective, (p. 449) Thus, we must exercise caution in our assumptions about families and be open to an inclusive approach when appropriate.

STRENGTHS OF PERSONS WITH BORDERLINE PERSONALITY DISORDER From any theoretical orientation, both the poem presented at the beginning of this chapter and the one below illustrate the intense suffering of people with borderline PD. However, it is equally clear that the poems and artwork presented in this chapter are the products of exceptionally sensitive and intuitive individuals. As clinicians, we tend to focus on psychopathology—finding out what is wrong so that we can help fix it. However, there is a growing movement to more fully integrate "positive psychology" (Seligman & Csikszentmihalyi, 2000) into our formulations. To ignore the power of the human spirit; the resiliency within all people; and, perhaps above all, the power of love, would be to paint only half the picture. We must fight within ourselves the tendency to split away and disregard the strengths that exist in these admittedly highly vulnerable individuals. The following poem is an illustration of the power of love between mother and child. According to the poet, Lauren Fechhelm (personal communication, December 11, 2002), the angel is her mother, who stayed with her and saw her through a terrifying psychotic episode. BORDERLINE PERSONALITY DISORDER

161

The Face of an Angel When tough times set in, you were by my side. I know my agony broke your heart. . . And when you thought things were getting better, 1 told you 1 did not want to live. But you did not want to believe, You would not believe, Because you could not bear to see me in pain again. Despairing, you still comforted your sobbing child . . . Because you were my angel. Demons swirled about my head and skeletons danced on my bed—but you stayed. And I was ashamed. To you I owe my life, My sanity, And my dignity. And thanks to you I will do great things with my life. A life that I once thought would never be. How can I ever repay you? 1 will find a way, because when I look at your face, I see the face of an angel. (L. Fechhelm, personal communication, 2001)

Is the angel-mother the "idealized part-object?" Is there evidence of "poor differentiation" in the poet's difficulty being separated from her mother? Perhaps. But what is more important is the universal human quality of the experience—the experience of love, gratitude, and triumph over severe adversity. This poem stands as a reminder of the strength and love that can exist in these families, love strengthened rather than weakened by shared adversity. TREATMENT PLANNING: SYNERGISTIC TREATMENT The therapist must first establish a working alliance with the person with borderline PD, which can entail significant challenges. Millon (1999) recommended starting with a supportive, nonconfrontational approach, using behavioral approaches to make some initial gains. Linehan (1993) and O. F. Kemberg et al. (1989) emphasized providing appropriate structure. Once rapport is established, behavioral interventions can be combined with medications if anxiety or depression are relatively severe. Cognitive interventions can help reduce irrational beliefs. Millon (1999) then recommended considering group and, later, family approaches to further enhance the client's interpersonal functioning. Treatment planning should attend to tangibly addressing the client's distressing symptoms. For example, an objective might be for the client to "report a reduction in feelings of emptiness and depersonalization"; appropri162

PERSONALITY-G U1DED THERAPY FOR DEPRESSION

EXHIBIT 7.2 Therapeutic Strategies and Tactics for the Prototypal Borderline Personality STRATEGIC GOALS Balance Polarities Reduce conflict between active-passive polarities Reduce conflict between pain-pleasure polarities Reduce conflict between self-other polarities Counter Perpetuations Reduce capricious emotionality Moderate inconsistent attitudes Adjust unpredictable behaviors TACTICAL MODALITIES Stabilize paradoxical interpersonal conduct Rebuild unstable self-image Steady labile moods Note. From Personality-Guided Therapy (p. 655), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

ate therapeutic interventions for this problem include mindfulness exercises such as "teach the client to increase his/her body awareness through an assigned exercise" and "explore aspects of the client's life that provide a sense of meaning, purpose, or mission" (Bockian & Jongsma, 2001, pp. 84, 90). The therapy should have a persistent theme of attending to the client's underlying ambivalence, reflected in the conflicts in Millon's (1999) three polarities (see Exhibit 7.2).

CASE EXAMPLE: DOUG The following is a synopsis of a case that I have discussed in greater detail in an earlier work (Bockian, 1994). Doug was 42 years old when I saw him on a spinal cord injury long-term rehabilitation unit. He was a Caucasian male of German and Irish background. A substance abuser at age 12, he left home at 16 and was addicted to heroin by age 18. He had spent 9 of the 11 years before I saw him in prison on a variety of charges related to a drugaddiction lifestyle (e.g., theft, assault, drug sales, and possession of illegal weapons). He had a long history of depression and suicide attempts. After falling off a railing, he sustained a spinal cord injury between the 6th and 7th cervical vertebrae; he thus had approximately 50% use of his arms, limited use of his fingers, and complete paralysis below the chest. The main problem that led to Doug's referral was verbal and physical abuse toward staff. He was also dangerously noncompliant with hospital rouBORDERLINE PERSONALITY DISORDER

163

tines; he smoked in bed, creating a fire risk, and refused his routine bowel care, which could lead to hypertensive crisis and death. These behaviors appeared manipulative to the staff and created a great deal of anger on the part of some staff; other staff believed his requests were reasonable. As is typical in cases of borderline PD, there was countertransferential anger and pity as well as substantial splitting among staff. Doug was also being withdrawn from methadone, about which he was ambivalent. There were a number of factors that I considered in conceptualizing this complex case. First and foremost, I wanted to understand how the client's personality was integral to the difficulties he was experiencing. With his violent and desultory history, the client superficially appeared to have a prototypical antisocial PD. However, the melange of reactions among the staff led me to consider borderline PD in addition, which turned out to be his primary diagnosis. This led to predictable vicious circles (Millon, 1996) that exacerbated existing problems. Not surprisingly, Doug's abuse was eliciting feelings of demoralization, helplessness, and dysphoria among some nurses while bringing out anger and frustration among others. Blocked from active aggression by their professional role and their moral values, many engaged in passiveaggressive behavior (e.g., being slow to answer his call bell). Such responses fueled Doug's indignation and strengthened his rationale (or, more accurately, his rationalization) for the "necessity" of the abusive behavior. Many on the staff experienced feelings of anger, frustration, and helplessness; as a group, nursing staff wanted the patient transferred to another facility to escape his irritating presence. Transfer was not an option in this case; moreover, if he were to be adequately rehabilitated, behavior change was essential, and merely passing him along would not be helpful to the patient or to the new facility. I further conceptualized the problem with abuse and the staffs response to it as being akin to that of a dysfunctional family. There was a central treatment team, consisting of the physicians, head nurses, psychologist, and social worker. The nursing staff, who were hierarchically lower than the treatment team, were the ones being abused. As in many dysfunctional families, unhealthy alliances were formed. Nurses who were being abused were angry. Several of those who got along well with Doug, on the other hand, experienced pride and blamed the abused nurses' lack of skill for their fate. Initially, I felt angry with Doug for his abusive behaviors, though my emotional reaction evolved over time. It was essential to pull the team together into a consistent stance. Drawing on Bateson's (1972) concept that changes in one part of a system can reverberate and lead to changes elsewhere in the system, I met with the "family members" (the treatment team, all three shifts of nurses, and the client) separately to facilitate differentiation (Bowen, 1966) and empowerment. Minuchin's (1974) theory suggests that intergenerational boundaries and hierarchies must be clear and appropriate in a healthy family. Thus, for ex164

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

ample, in a family with young children, the parents need to be in charge, setting rules and guidelines. Family pathology can undermine this framework; for example, in families in which one or both of the parents is an alcoholic, the oldest child is often "parentified," or given responsibilities (such as getting the younger children fed and off to school) that are ordinarily reserved for parents. Because parentified children lack full parental authority and, because of their youth, typically lack adequate parenting skills, systems that contain parentified children are generally chaotic. In this case, I conceptualized issues of boundaries and hierarchy as central to the difficulties that were occurring. As alluded to above, nurses were functioning almost as "parentified children," given responsibilities to care for the client but inadequate power to effect necessary changes; further, lacking adequate mental health training, they were not equipped to deal with this complex client's abusive behavior. I believed that it was necessary to provide the nurses with the tools they needed to handle the abuse problem and to have the treatment team give them the support they needed. I applied to the central administration of the hospital to institute a "zero tolerance for abuse" policy, which was passed quickly. This provided institutional support for the next intervention, which was to have nurses inform an abusive client (specifically Doug, in this case) that if he was abusive the nurse would inform him that his behavior was abuse and leave the room. Simultaneously, we instituted a behavioral contract that specified consequences for problematic behavior (e.g., abuse and smoking behavior). Within a week or two, Doug's problematic behavior had dropped from 30 episodes a month to about 4, and even the episodes that did occur were less problematic. There was no abusive behavior, and the occasional treatment refusals were more appropriate and less a function of acting out. By the end of 2 months, when he was discharged, he was on such good terms with the nurses that he bought them pizza to thank them for their care for him. The staffs emotional reaction to him, of course, changed substantially, with most having a positive feeling for him. After the abusive behavior stopped, I also felt more positive, with feelings of respect, amusement (he could be quite funny), and compassion (he had some difficult situations to confront) being most prominent. Culturally, the most relevant factors were not his gender or Euro-American origins but rather prison culture. His refusal to comply with hospital routines symbolized his tenacious refusal to accept subordinate status. In prison, accepting subordinate status entailed a variety of forms of physical, mental, and sexual abuse that Doug, understandably, fought off. Using cognitive techniques, I was able to help Doug process the nature of his inappropriate generalization from prison culture to hospital culture. In sum, then, in this case I identified vicious circles and problematic interactions, conceptually guided by personality constructs (borderline and antisocial). Initially, I used a combination of behavioral and family techBORDERLINE PERSONALITY DISORDER

165

niques to help bring a chaotic situation under control. Afterward, aware of culturally relevant factors, I was able to discern some of the motives for the client's behavior, and challenge them using cognitive-behavioral therapy. From a personality-guided therapy perspective, what is notable in this case are the synergistic and catalytic sequences of interventions, guided by the personality dynamics of the client, and the interpersonal sequelae thus entailed. One area that would have been worth exploring, in retrospect, was Doug's neuropsychological status. It is likely that he had neuropsychological deficits, whether he was born with them or acquired them through violence, substance abuse, or head trauma (e.g., the fall that broke his neck). Such factors may have contributed to misperceptions, poor judgment, and impulsivity. Although there was a good outcome in this case, knowing his neuropsychological status could have helped us to fine-tune his postdischarge adjustment through both rehabilitation and disability accommodation. Further, one of the biggest problems Doug had is that for many years he had been treated as someone with antisocial PD when really he primarily had borderline PD. Discriminating between the two disorders, by understanding the reason for the acting-out behavior, was very important in optimizing treatment. Consistent with the major tenets of this chapter, correctly identifying Doug's primary personality pattern led to appropriate and attuned interventions. Doug was labile and impulsive. In my experience, those who viewed him as callous and manipulative related to him poorly and were not helpful; conversely, in a case of "pure" antisocial PD, failing to identify the client's manipulations can be highly problematic and can undermine the relationship.

SUMMARY AND CONCLUSIONS Treating depression in the context of a person with borderline PD is a significant challenge. The characteristic style of the individual interferes with the therapeutic relationship unless active measures are taken to promote an appropriate one. Leading psychodynamic theorists (Clarkin et al, 1999) and cognitive-behavioral/dialectical behavior therapists (A. T. Beck et al., 2004; Linehan, 1993) have agreed that providing structure (e.g., on ways to handle session length, session frequency, billing, suicidal behavior, etc.) is one of the keys to success with this population. Personality-guided therapy principles indicate that catalytic sequences of interventions will be most effective. Linehan's (1993) integration of cognitive, behavioral, and mindfulness strategies is a good illustration of this principle. In the case illustration, the arrangement of interventions in a manner that provided a sense of safety—"family" interventions to create appropriate boundaries followed by interpersonal strategies to enhance relationships and cognitive strategies to challenge Doug's erroneous beliefs—led to substantial change in a relatively brief period of time. 166

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Future research clarifying the nature of the relationship between borderline PD, depression, and suicidal behavior would be extremely helpful. The person with depression and borderline PD appears to be at higher risk for suicidal behavior than those with either condition alone (e.g., Friedman et al., 1983), though additional research is necessary. In addition, research on combinations of synergistic interventions would be useful in clarifying the impact of different interventions and their timing; such studies may also shed light on conceptualization of the treatment of borderline PD.

BORDERLINE PERSONALITY DISORDER

167

8 DEPRESSION IN HISTRIONIC PERSONALITY DISORDER

As the name of the disorder suggests, histrionic features abound in the world of theater and film. The exaggerated behaviors of actors and actresses on talk shows and in other venues generally illustrate subclinical and healthy-range histrionic features. In most cases, people are amused and entertained by their antics, thus illustrating the more positive aspects of such characteristics. Most television shows, with their 30- or 60-minute formats; brief, dramatic confrontations; and artificially rapid problem resolutions are veritable instruction manuals on how to have a histrionic personality disorder (PD). In its more severe form, histrionic PD is often painful to individuals, especially as they approach and surpass middle age. The emotional roller coaster, the lack of stable relationships, and the unfillable craving for attention wear on them. As they age, the once charming and seductive flirtations become less effective and are at times even grotesque. The character Blanche DuBois, from the play A Streetcar Named Desire (T. Williams, 1953/1974), illustrates some of the more tragic aspects of histrionic PD. Her attempt to create an illusion based on appearances ultimately failed, whereas a simpler, more honest approach may have allowed her to develop the relationships she 169

desired. Her history of seductiveness led to her inability to hold on to her teaching position. Her instrumental incompetence (e.g., mismanaging the family fortune) and life strategy—"I have always depended on the kindness of strangers"—contributed to her tragic demise. The following scene illustrates Blanche's inappropriate seductiveness with Stanley, her sister's brutish husband. Stanley believes that Blanche has inherited money that she is hiding from him. Stanley:

There is such a thing in this state of Louisiana as the Napoleonic code, according to which whatever belongs to my wife is also mine—and vice versa.

Blanche:

My, but you have an impressive judicial air! [She sprays herself with her atomizer; then playfully sprays him with it. He seizes the atomizer and slams it down on the dresser. She throws back her head and laughs.]

Stanley:

If I didn't know that you was my wife's sister I'd get ideas about you. (T. Williams, 1953/1974, pp. 40-41)

There is almost palpable tension as one can sense the tragedy that will unfold from her relentless poor judgment.

PHENOMENOLOGY: THE EXPERIENCE OF HISTRIONIC PERSONALITY DISORDER Histrionic PD has been defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM—IV—TR]; American Psychiatric Association, ZOOOa) as "a pervasive pattern of excessive emotionality and attention-seeking behavior" (p. 711). The individual with histrionic PD tends to be dramatic, seductive, and flirtatious. The individual often is shallow, focusing on superficialities; a heterosexual woman with histrionic PD may describe the type of car a man drives, the way he wears his hair, or the way he dresses rather than his personal qualities as critical elements in a relationship. Depressed persons with histrionic PD express their depressive symptoms in dramatic terms. Another notable phenomenon is that with their rapidly shifting emotions, individuals with histrionic PD may be in tears one moment and then, when discussing a new topic, seem fine. This should not be misconstrued as faking depression to attain sympathy in a manipulative, conscious way. Typically, they are genuinely experiencing distressing sadness. The easy distractibility and quasi-dissociative inner experience of persons with histrionic PD, however, make it possible for them to isolate affects within the session. If the therapist guides the topic back to the distressing material, the depressive affect reliably reemerges.

170

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

EPIDEMIOLOGY According to the DSM-IV-TR, histrionic PD occurs in approximately 2% to 3% of the general population. In inpatient and outpatient settings, histrionic PD has a prevalence of approximately 10% to 15%. A number of studies have investigated the prevalence of histrionic PD in depressed samples. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 9.5% had histrionic PD. In Pepper et al.'s (1995) dysthymic disorder sample, 14% had histrionic PD. In another sample of depressed clients, approximately 3% had histrionic PD (Fava et al, 1995). In a sample of 249 depressed outpatients, 4% were diagnosed with "definite" and 9% with "probable" histrionic PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; 12% had histrionic PD. In a sample of 352 clients with both anxiety and depression, approximately 11% had histrionic PD as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, 6k Dunner, 1993). Thus, in depressed samples, approximately 3% to 14% had histrionic PD. Conversely, looking at the rate of depression in individuals with histrionic PD, Zimmerman and Coryell studied a community sample of 797 individuals that included 143 individuals who were diagnosed with personality disorders. Among those with histrionic PD, 45.8% met the criteria for major depression.

WHY DO PEOPLE WITH HISTRIONIC PERSONALITY DISORDER GET DEPRESSED? People with histrionic PD become depressed for a variety of reasons. Interpersonal rejection is extremely difficult for most people with histrionic PD to take. Their flightiness and shallow object relations mean that their depression may be short-lived if they can find another relationship, which entails a risk of premature termination of therapy. Millon (1999) noted that dysthymia among individuals with histrionic PD is often associated with their feelings of inner emptiness; extremely other-oriented, individuals with histrionic PD experience a sense of aimlessness and purposelessness when inbetween relationships with others. Given that the rates of depression appear to be higher for individuals with histrionic PD than in the general population, it appears that histrionic PD creates a vulnerability to depression (see chap. 2, this volume, for further discussion of theoretical models of the relationship between depression and Axis II disorders).

HISTRIONIC PERSONALITY DISORDER

171

HOW A PERSON BECOMES AND REMAINS HISTRIONIC: THEORIES OF HISTRIONIC PERSONALITY DISORDER Biological Factors According to Cloninger (1987), histrionic PD would be described as involving high novelty seeking, low harm avoidance, and high reward dependence. High novelty seeking is related to complex interactions among dopaminergic systems within the brain. Noted Cloninger (1998), Mesolimbic and mesofrontal dopaminergic projections have been shown to play a crucial role in incentive activation of each aspect of novelty seeking. Dopamine depleting lesions in the nucleus accumbens or the ventral tegmentum lead to neglect of novel environmental stimuli and reduce both spontaneous activity and investigative behavior. (Cloninger, 1998, p. 71)

Reward dependence was defined by Cloninger (1998) as "a heritable predisposition for facility in the development of conditioned reward, particularly social cues" (p. 72). High reward dependence is related to elevated activity in the thalamus, which is consistent with the theory that serotonergic projections from the thalamus to the median raphe nuclei play an important role in social communication (Cloninger, 1998). Thus, science is gaining preliminary understanding of some of the activity in the brain associated with histrionic PD. Heritability

The heritability of histrionic PD appears to be similar to that of other PDs. Coolidge, Thede, and Jang (2001) found a heritability of .79 for histrionic PD in their study of child and adolescent twins. A meta-analysis by McCartney, Harris, and Bernieri (1990) showed a higher interclass correlation for monozygotic twins (.51) than dizygotic twins (.19) on a measure of the normal trait, sociability. Livesley, Jang, and Vernon (1998) found that the Dimensional Assessment of Personality Pathology measure of affective lability, a dimension relevant in many people with histrionic PD, had a heritability of 38.4%. DiLalla, Carey, Gottesman, and Bouchard (1996) found the following heritability on Minnesota Multiphasic Personality Inventory scales, which are partially related to the histrionic PD prototype: Hysteria: 26%; Masculinity/Femininity: 36%; Hypomania: 55%. Medications

To my knowledge, the only empirical study that specifically addressed the use of medications with individuals with histrionic PD was Ekselius and von Knorring's (1998) uncontrolled trial of the selective serotonin reuptake inhibitors sertraline and citalopram (see chap. 1, this volume). The study had mixed results. In the citalopram group, 8 of 13 individuals with histri172

PERSONALITY^ UIDED THERAPY FOR DEPRESSION

onic PD in their sample (61.5%) achieved remission after 24 weeks of treat' ment, which was statically significant; however, in the sertraline group, only 1 of 9 achieved remission, a statistically nonsignificant decrease. Both the sertraline group and the citalopram group had a mean decrease of 0.2 criterion pre- to posttreatment, which was statistically nonsignificant. Unfortunately, because there was no medication-free comparison group, the results of the study are inconclusive. In the absence of further scientific data, it is worthwhile to consider the conceptualization provided by Joseph (1997) on the basis of clinical observation. He argued that there are three symptom clusters that respond to medications that are relevant to histrionic PD. The first is the individuals' heightened emotional sensitivity, sensitivity to rejection, and irritability. These symptoms, he asserted, respond to serotonergic antidepressants venlafaxine, or nefazodone. (For the depressed person with histrionic PD, selective serotonin reuptake inhibitors can serve a dual purpose.) The second symptom cluster relates to the high energy level and scattered presentation of people with histrionic PD, conceptualized as hypomanic symptoms; appropriate medications are mood stabilizers such as lithium, valproate, or carbamazepine. Finally, the proclivity of individuals with histrionic PD to jump from topic to topic and their lack of focus may be neurologically related to attention deficit disorder. In such cases, stimulants (e.g., methylphenidate) or bupropion would be indicated. Joseph's (1997) observations, though insightful and rational, must be backed by science. Empirical studies leading to randomized clinical trials are necessary to verify the appropriateness of various medications for histrionic PD. Psychological Factors Millon's Theory According to Millon's (1996) tripolar model, histrionic PD represents the "active-dependent" prototype. Unlike the passive-dependent type (dependent PD), who waits and hopes for attention and nurturance, persons with histrionic PD demand attention. They use a variety of tools and strategies, including energy and charm on the positive end to demandingness and melodrama on the more negative end, to obtain the attention they crave. In terms of their presumed pathogenic background, Millon (1981) noted that the child is born with an active temperament and is likely to engage energetically with the environment. Parents and other significant figures reward the child for performing and may discourage instrumental competence. The child is rewarded for being charming, engaging, and cute. Thus the child learns to derive nurturance and support by performing for others. A description of the histrionic prototype in terms of Millon's domains is given in Appendix B. Fickle mood and attention seeking are the most prominent features of the disorder. HISTRIONIC PERSONALITY DISORDER

173

Cognitive-Behavioral Conceptualization and Interventions Individuals with histrionic PD are prone to hold a number of different beliefs that are associated with their dramatic yet dependent behaviors. They may have automatic thoughts such as, "I want him to notice me," and "I'm bored!" Intermediate beliefs would include, "Unless I am the center of attention, it is awful," and "I will only do something if it's fun." A. T. Beck, Freeman, and Davis (2004) noted the underlying core belief, "I am inadequate and unable to handle life on my own" (p. 225). This belief and many of the corresponding intermediate beliefs and automatic thoughts are depressogenic as well. In addition, confusion about their identity may emerge in thoughts such as, "As long as I do what I feel like doing in the moment everything will be fine," and, perhaps most important, "I don't mind, I'll just go along with what everyone else wants to do." Identity confusion is often emotionally painful and can contribute to depressed mood. Such individuals often engage in emotional reasoning—that is, believing that a feeling is strong evidence that something is true. For example, depressed individuals with histrionic PD may be prone to thinking, "If I feel like a failure, then it means that I am a failure." DSM-IV-TR described their thinking as "global and impressionistic"; in cognitive terms, this indicates that they are likely to make the error of overgeneralization. For example, they may see one rejection as evidence that they will always be rejected. Similarly, individuals with histrionic PD are prone to dichotomous thinking—for example, seeing others as "good" or "rotten." The client needs to learn to challenge these beliefs. Socratic dialogue and thought records can be helpful to persons with histrionic PD, helping them to relate their feelings to their thoughts. The capacity to think clearly, logically, and persistently is a great gift that cognitive therapy can offer the often flighty or disjointed person with histrionic PD. Of the behavioral techniques, assertiveness training can be especially helpful in countering manipulative behaviors (such as tantrums) and in helping the individual to know his or her genuine needs. Problem-solving skills can also be useful in helping the individual to achieve genuine competence and self-satisfaction. A. T. Beck and Freeman (1990) suggested the use of a paradoxical technique for the treatment of depression in histrionic PD: For patients who feel reluctant to give up the emotional trauma in their lives and insist that they have no choice but to get terribly depressed and upset, it can be useful to help them gain at least some control by learning to "schedule a trauma." Patients can pick a specific time each day (or week) during which time they will give in to their strong feelings (of depression, anger, temper tantrum, etc.). Rather than being overwhelmed when such feelings occur, they learn to postpone the feelings to a convenient time and keep them within an agreed-upon time frame. This often has a paradoxical effect. When patients learn that they can indeed "schedule depression" and stick to the time limits without letting it interfere 174

PERSONALITY-G HIDED THERAPY FOR DEPRESSION

with their lives, they, rarely feel the need to schedule such time on a regular basis, (p. 230)

The authors found that this technique often provides a way for clients to manage their depression long after termination. Psychodynamic Therapy

According to P. Kernberg, Weiner, and Bardenstein (2000), histrionic PD represents the extreme end of the hysterical personality type and thus falls within the borderline level of personality organization. The hysterical personality is in the neurotic range of functioning. In recommending psychodynamic treatment, they noted that the optimal treatment is psychoanalytic or expressive psychoanalytic psychotherapy to resolve the conflicts around dependence and sexual inhibitions due to guilt over incestuous wishes. Addressing issues of rivalry and envy affecting friendship and love relationships are also goals of treatment, (p. 107)

The critical intervention is the confrontation of the transference in the here and now. Family Systems

Individuals with histrionic PD are often drawn to partners with obsessive-compulsive features. It is from such relationships that the phrase "opposites attract" seems to draw much of its strength. Prototypically, the histrionic woman is attracted to the stability of the obsessive—compulsive man. His ability to stay focused on tasks, dedicated to long-term goals, and stoic in the face of adversity is overwhelmingly appealing. Conversely, the obsessive-compulsive man feels like the "strong one" in the relationship, making him feel like a "real man," sometimes for the first time. When he is with her, his self-doubts vanish; in patiently listening to her and supporting her, he feels strong and good. Through her, he is able to experience emotionality, spontaneity, and fun. Each derives vicarious emotional satisfaction from the other. To a certain extent, the attraction is based not on similarity and mutual interests but rather on the prospect of making each individual in the partnership whole, to fill in a "missing piece" (Sperry & Maniacci, 1998). In many such relationships, over time the poor differentiation and unrealistic expectations on the part of the person with histrionic PD of what the relationship can provide create a tremendous strain and lead to significant depression and other problems in one or both partners (Sperry & Maniacci, 1998). The histrionic wife is disappointed with her "stick-in-themud" husband, who is too involved with his work to pay attention to her, and too "boring" for her even when they are together. His indecisiveness makes him seem "weak" to her, and she may become castrating or provocative. She may flirt with other men in front of him, secretly hoping to provoke HISTRIONIC PERSONALITY DISORDER

175

a strong, rescuing reaction; instead, he rationalizes and withdraws. Seeing this as more evidence that he does not care, she becomes increasingly provocative (e.g., by having an affair) or despairs and becomes depressed or suicidal. The husband, meanwhile, becomes increasingly angry at the acting-out wife, ultimately feeling completely exploited. If the wife instead is suicidal or depressed, the husband is more likely to feel burdened and overwhelmed. Sperry and Maniacci (1998) described three phases in treating the histrionic-obsessive couple. The first phase is to establish a working alliance. It is useful to establish the expectation that neither person in the couple is "crazy" or "the mentally ill one" (a label often self-applied by the suicidal or depressed histrionic partner). Instead, the explicit therapeutic expectation is that each individual will take responsibility for his or her contribution to the extant problem. By maintaining this neutral stance, the therapist conveys reassurance to the histrionic partner, reducing her fears of abandonment, and also eliminates mental illness as an excuse to act out. Discussing family of-origin issues can also help make confusing patterns understandable. The second phase is rebalancing the couple relationship. Histrionicobsessive couples typically present with imbalances in boundaries, power, and intimacy. Problems in boundaries and power respond well to structural and strategic therapy, and communication and family-of-origin approaches can be used to improve intimacy. The third phase is modifying each partner's individual dynamics. In general, in this phase, the goal is to help each partner to become more honest, forthright, and assertive. Noted Sperry and Maniacci (1998), Both the histrionic and the obsessive partners are often dishonest in their attempts to control each other. She misrepresents facts, dishonestly seduces, and exaggerates her feelings, while he pretends he has no personal needs or desires, or that he is not bothered by her behavior. In addition, she pretends utter helplessness, feigns illness, threatens suicide, and finds other unfair means of exerting enormous pressure on him. He, for his part, resorts to passive—aggressive tactics, such as physical and emotional withdrawal, avoidance of feelings, procrastination, and indecisiveness. (p. 197)

Numerous techniques are available to help the clients improve; Sperry and Maniacci (1998) mentioned cognitive-behavioral couples therapy and Adlerian couples therapy. Once clients make adequate changes in their selfconcept and their expectations of the relationship, there are substantial improvements in the relationship. In some cases a fourth phase, skills training, is necessary. In such cases, skills training is usually done concurrently with the second phase, rebalancing the couple.

176

PERSONALJTY-G L7IDED THERAPY FOR DEPRESSION

Group Therapy Individuals with histrionic PD are in some ways naturals for group treatment. There is a concern, given that it is an explicit criterion in DSM-IVTR, that clients will feel uncomfortable if they are not the center of attention in a group. If a group norm is established that everyone will have an opportunity to participate, and if clients see that their contributions are valued even when their problems are not the main topic of conversation, then they can gain valuable perspective. Their people-pleasing proclivities tend to facilitate rapid joining with the group (though their need for constant attention puts them at risk for becoming monopolizers). Further, sometimes they can see in others what they resist seeing in themselves, or they can hear from a peer what they cannot process from the therapist. Psychodrama is a technique that may be particularly well suited to individuals with histrionic PD. It gives them a role to play, whether their problems are the focus of attention or not. It also takes advantage of their attraction to theatrics. Perhaps surprisingly, a search on PsycINFO for "psychodrama and histrionic personality disorder" yielded only one hit, an article entitled "Psychodrama With the Hysteric" (Clayton, 1973).

COUNTERTRANSFERENCE Similar to clients with borderline PD, individuals with histrionic PD can pull powerfully for therapists to play the role of "rescuer." Rather than being pulled into such a role, therapists are well advised to examine their thoughts and motivations and continue to encourage a collaborative relationship (A. T. Beck et al., 2004). Therapists who do get drawn in are likely to find, at some point, that they feel manipulated and thus frustrated and angry. In addition, the client's meager and superficial inner world can be frustrating to therapists as well and lead to feelings of hopelessness. For example, a case report indicated that a client with histrionic PD had almost no awareness of any thoughts that took place in association with a panic attack other than "I'm going to faint." The therapist had thoughts such as "Why bother with this? Nothing sinks in. It won't make a difference" (A. T. Beck et al., 2004, p. 228). Therapists in such situations must challenge their thoughts and will often benefit from consultation. Additional information regarding countertransference with histrionic PD can be gleaned from the psychodynamic literature on the hysterical personality, a similar but somewhat less severe variant. Lionells (1986) noted that therapists often experience anger, contempt, and frustration in response to clients' manipulations. Feelings of sexual attraction are common because of clients' (unconscious) seductiveness (Berger, 1971; Eriksson, 1962; Farber, 1961; O. F. Kernberg, 1992; Lionells, 1986; Muslin & Gill, 1978).

HISTRIONIC PERSONALITY DISORDER

177

A study I performed with psychotherapy graduate students showed that the most prominent feelings in response to a filmed representation of histrionic PD were amusement, curiosity, irritation, fascination, embarrassment for the client, empathy, and energy; participants also found themselves "leaning forward" and "leaning back" (Bockian, 2002a; see also chap. 1, this volume, for a description of the study). It appears that there were two main emotional reactions, one of which was positively tinged (feeling amused, curious, empathetic, and energized and leaning forward) and the other negatively tinged (feeling irritated and embarrassed for and leaning back). Informally, through class discussions, it appeared that women sometimes felt competitive with a woman portrayed as a seductive histrionic, and some felt angry ("That is the kind of girl who'll steal your boyfriend!"); this is consistent with psychodynamic theory (P. Kernberg et al., 2000) and L. S. Benjamin's (1996a) interpersonal theory. Gender appeared to play a role; informal discussions suggested that students were less judgmental of a histrionic man who was sexually promiscuous than of a woman who alluded to being an exotic dancer (but who was not sexually promiscuous). Although sexual attraction was not listed as one of the top 10 items, it is a possible response to seductiveness. I generally enjoy people with histrionic PD. 1 enjoy the show. I just make sure to track the person and bring him or her back to the topic at hand, and it generally works out. Many have a well-developed sense of humor, which is a strength. When the PD is severe and the individual is chaotic, scattered, and extremely dramatic, the countertransference becomes more challenging; I tend to experience frustration, or the thoughts, "Why don't you give it a rest!" and "Just get real!" In such cases, I use the cognitive approach alluded to previously: I ask myself, "What is it like to be that person? What would it be like if others did not take me seriously? If people could not follow my scattered thoughts? If I had little access to my personal history? What would it be like if others were irritated with me when I wanted so badly to be liked?" This kind of analysis usually leads to improved empathy.

SOCIAL CONSIDERATIONS AND DIVERSITY In making a diagnosis of histrionic PD, one should be careful to take into account gender and cultural norms regarding behaviors such as flirtation, dress, and attention seeking. What is considered excessively flirtatious for women, for example, may be considered acceptable for men. In some cultures, such as Hispanic culture, louder forms of dress and more dramatic behaviors may be socially acceptable or even admirable. DSM-IV-TR explicitly listed "macho" behavior as a potential sign of histrionic PD in men; obviously, within Hispanic culture, macho behaviors are not considered to be pathological (Castillo, 1997). 178

PERSONALITY-GLTOED THERAPY FOR DEPRESS/ON

According to DSM-IV-TR, studies have found that histrionic PD occurs more frequently in women but that the ratio is no higher than the ratio of women to men in the sample as a whole. Although noting that the disorder may be expressed differently in women and men, the DSM-IV-TR provided no guidance on how to avoid gender stereotypes that may lead to improper diagnosis and seemed to imply that gender bias is not a problem. A growing body of literature, however, has suggested that clinicians tend to see women as more histrionic and that there are diagnostic biases that favor diagnosing women with histrionic PD (K. G. Anderson, Sankis, & Widiger, 2001; Erickson, 2002; Garb, 1997; Sprock, 2000). Clinicians should exercise caution in carefully attending to whether the behaviors are causing distress or functional impairments in the individual before applying the histrionic label, particularly for women. It does appear, however, that the field is making progress in reducing gender bias, primarily through making the criteria more gender neutral; in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987), histrionic PD was described as being diagnosed much more frequently in women than in men.

STRENGTHS OF PERSONS WITH HISTRIONIC PERSONALITY DISORDER The strengths associated with histrionic features are a sense of liveliness, the ability to have fun and to provide fun for others, and sociability. Often, such individuals can be charming and charismatic, which is a great strength if appropriately channeled. Some aspects of histrionic PD are helpful for a variety of professions, most notably the entertainment field, but also sales, teaching, and any other profession that involves engaging others' attention.

TREATMENT PLANNING: SYNERGISTIC TREATMENT Because the person with histrionic PD is considered the active-dependent type, then naturally, the goal is to balance the polarities by helping the client to become less hyperactive, less demanding, more independent, and more self-focused. It is also important to undercut processes that tend to perpetuate the histrionic pattern. Vicious circles of the person with histrionic PD include (a) failure to integrate experiences because of their external preoccupation; (b) massive repression, which undermines their ability to learn from experience; and (c) superficial relationships—moving from person to person precludes their developing deeper and more meaningful relationships, further interfering with their ability to learn from experience. Thus, therapy HISTRIONIC PERSONALITY DISORDER

179

EXHIBIT 8.1 Long-Term Goals for Histrionic Personality Disorder 1. 2. 3. 4. 5. 6. 7. 8.

Reduce focus on gaining attention from others, while strengthening self-awareness and self-image. Decrease manipulative actions designed to gain attention from others. Form genuine social relationships. Decrease seductive behavior and excessive use of physical appearance to secure attention. Stabilize erratic moods and dramatic displays of emotion. Reorient flighty cognitive style, increasing attention to relevant detail. Improve self-esteem. Decrease suggestibility.

Note. From The Personality Disorders Treatment Planner (pp. 169-170), by N. R. Bockian and A. E. Jongsma, 2001, New York: John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

should be geared to reduce their external preoccupation, deepen their social relationships, and expand their depth of knowledge (including their selfawareness and awareness of relationship histories). The long-term goals for individuals with histrionic PD are listed in Exhibit 8.1. In addition, goals based on their depression would include being able to recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma & Peterson, 1999). The path to effective treatment is to assemble catalytic sequences that synergize and build on one another. For clients with histrionic PD and depression, helping to stabilize their excessive emotionality would generally be the most appropriate first step; if too labile, the client is unlikely to be able to process potentially helpful interventions. Behavioral skills, such as relaxation training, and cognitive interventions, such as Socratic dialogue, will further help to stabilize the individual. Once an alliance is formed, antidepressant medication can be considered. Prone to believe in quick fixes, individuals with histrionic PD may lose motivation for treatment if medications are introduced too quickly, so the clinician should carefully consider the timing of psychopharmacological interventions. Mindfulness meditation (Kabat-Zinn, 1990; Linehan, 1993) is an intervention that could potentially have extremely powerful and direct effects on histrionic symptoms such as difficulties with introspection and focusing. Although sitting meditation may be difficult for clients who are restless or who have attention-deficit/hyperactivity disorder symptoms, movement-based meditation (e.g., yoga) can be substituted or added to attain similar results more comfortably. A combined meditation and yoga program has also been shown to have powerful effects on depression, comparable to the effects of psychotherapy (J. J. Miller, Fletcher, & Kabat-Zinn, 1995). Family and couple therapy can help to break reinforcement of histrionic patterns that others may unwittingly be providing. Group therapy can be especially powerful for people with histrionic PD, with psychodrama being a potentially excellent fit (Clayton, 1973). Depth approaches, such as psychodynamic interventions, would generally come last because they 180

PERSONALITY^ U1DED THERAPY FOR DEPRESSION

EXHIBIT 8.2 Therapeutic Strategies and Tactics for the Prototypal Histrionic Personality STRATEGIC GOALS Balance Polarities Diminish manipulative actions Moderate focus on others Counter Perpetuations Reverse external preoccupations Kindle genuine social relationships Acquire in-depth knowledge TACTICAL MODALITIES Decrease interpersonal attention seeking Stabilize fickle moods Reduce dramatic behaviors Reorient flighty cognitive style Note. From Personality-Guided Therapy (p. 408), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

tend to produce change more slowly and thus require greater motivation on the part of the client; in addition, the capacity to introspect may be built up through other methods, which would then permit a psychodynamic approach to proceed more efficiently. The current therapist can implement psychodynamic interventions, though in some cases it would be wise to refer the client, thus allowing the transference to form anew. Throughout any form of treatment, the client's reaction to the therapist (transference) and the therapist's reaction to the client (countertransference) can be effectively monitored by using psychodynamic concepts (see Exhibit 8.2).

CASE EXAMPLE: MIKO At the time that I saw her, Miko, a Japanese American woman who was self-referred for treatment, was 23 years old. Her long black hair was meticulously brushed, and her makeup was attractively applied. She wore a brightcolored dress, part of a well-coordinated outfit. Her eye makeup made her lashes look long and full and gave her a wide-eyed appearance. A part-time aerobics instructor, Miko was very fit. Overall, her appearance was very attractive. Miko had recently graduated from a state university and was an extraordinarily active woman. In addition to holding a full-time job, she was a part-time actress in a comedy troupe and, until shortly before she began therapy, was a cocktail waitress. She worked diligently at improving her im-

HISTRIONIC PERSONALITY DISORDER

181

provisation comedy skills and dreamed of being a professional actress some day. Although composed while she provided routine intake information, when asked what brought her to the clinic, she became tense and fidgety. Although her eye contact had initially been unusually good, she glanced all around the room. Finally, with tears starting to form in her eyes, she half blurted, half choked out, "I was raped." Tears were now flowing down her cheeks, but she remained silent. She accepted the tissue I offered her gratefully, and she then related what had happened. Miko had been working her usual shift as a cocktail waitress. That night, there was a celebration after work. She had had three beers over a 2-hour period, and, with her rather small frame, she was "pretty tipsy, but not drunk." She knew that driving was not a good idea. The bartender, Henry, offered to drive her home, and she accepted. Instead of taking her back to her home, Henry took her back to his apartment. He then forced her to have oral sex with him, threatening her with violence if she did not comply. She remembered him initiating sexual contact, and then she blacked out, unable to remember anything further about that night. She woke up the next morning in her bed. The next day Miko quit her job at the bar. Miko reported difficulty in her day-to-day activities. She had problems sleeping, being plagued by troubling dreams about the event. When she was not engaged in highly absorbing activities, her mind would drift to the rape; driving was especially difficult, and she had to pull off to the side of the road to compose herself several times per week. In addition to the obvious posttraumatic stress disorder or rape trauma syndrome symptoms, Miko was experiencing a major depressive episode. She had depressed mood much of the day, feelings of shame, and loss of appetite. Rapport was established quickly and without much difficulty. Miko's symptoms were very distressing, and she was eager to get well. Her Millon Clinical Multiaxial Inventory—II score demonstrated a prominent elevation on the Histrionic scale, with a secondary elevation on the ObsessiveCompulsive scale and a tertiary elevation on the Dependent scale. Her strengths were her liveliness and vivaciousness (which became more apparent as the depression lifted), her determination, and her commitment to being a good employee and a good actress. Her main weaknesses were her interpersonal naivete and her lack of self-awareness. My initial emotional reactions to Miko were feelings of sympathy and compassion and feelings of sexual attraction. These are fairly common responses that I have to individuals with histrionic PD or features. I wondered to myself if others felt this way and, more specifically, if her attractiveness to me was part of a general pattern of seductiveness. The therapy ultimately presented opportunities to evaluate this issue. In terms of transference, Miko initially demonstrated a strong need for approval and a strong proclivity to be entertaining. At times, she would bring in material from her comedy rou182

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

tines, which were indeed quite funny. She was prone to use humor as a way to relieve tension, which was a great strength for her; however, it also distracted her from getting around to deeper issues that might help her to work through the anxiety. I made it a point to remember what we were discussing before she went into her comedy mode. 1 would enjoy the show for a few minutes and then I would remind her of where we were and encourage her to continue to process what we had been discussing. At the end of therapy, 1 asked her what had been most helpful to her; she responded, in essence, that I gave her space to joke around but always brought her back to the issue at hand. Despite her numerous strengths, including a high IQ and strong interpersonal skills, Miko was prone to distractibility and a fragmented presentation common to people with histrionic PD. What was initially essential in treatment, of course, was to deal with the problems related to her sexual assault. Like many victims, Miko largely blamed herself. She felt deeply ashamed, believing that she had been "dirtied" and that she would bring disgrace to her family. Although not especially prone to guilt generally, she felt guilty about being raped, implying that it was her fault. Dealing with such issues can be rather tricky. To say it was not her fault and there was nothing she could have done would have alleviated guilt at the expense of increasing fear; if she truly believed that, then she could never feel safe. Conversely, to say that there was something she should have done would have increased guilt and shame. Her guilt feelings were challenged using cognitive techniques, particularly Socratic dialogue. As we reviewed the evidence, it became clearer to Miko that she had not asked for this to happen and that it really was not her fault. I also explicitly stated, in no uncertain terms, that Henry was wrong and that nothing that Miko did warranted what had happened; this was important, because later we would be investigating issues (such as how to stay safe, or her personality characteristics) that could be misinterpreted as blaming or internalized as self-blame. Miko's feelings of shame and guilt subsided as these new beliefs became more habitual. Simultaneously, we focused several months of therapy on the issue of how to stay safe. She took numerous practical precautions, such as getting to know men well before she would be alone with them; avoiding being out alone late at night; and, most meaningfully to her, avoiding alcohol. One issue that we discussed was to pay attention to whether a man objectified women. Miko noticed, in retrospect, that Henry objectified women and that generally his relationships lacked a meaningful personal quality. Miko avoided men with these characteristics. Miko initially could garner little social support from her family because she did not want to tell them what happened. When I asked Miko to describe her childhood, she stated that "everything was great" and her parents were "wonderful." I found myself struggling to get a sense of what her experiences were as a child, because her descriptions tended to be very broad and lacking in detail. Although I could not quite understand how her relationships with HISTRIONIC PERSONALITY DISORDER

183

her family members could be so good and yet she could not tell them about her sexual assault, I attributed this to cultural issues. In Japanese culture, shame is an extremely powerful emotion and plays a central role in society. Loss efface can be considered worse than death, as illustrated by the ancient seppuku1 ritual, in which a samurai (warrior) commits suicide to preserve his honor. We discussed the issue on a number of occasions over several weeks; I neither encouraged nor discouraged her from discussing it with her parents. She ultimately decided to tell them; although shocked and pained, they were supportive and helpful, and Miko felt relieved. Miko's personality was extremely important to working through her depression. We were able to draw on her outgoing nature and sense of humor to help to reestablish feelings of pleasure and the sense of approval that she enjoyed. Later in therapy, we would work on her need for approval and help her to be more independent; this could be conceptualized as helping her to balance out Millon's self-other dimension. Miko's depression was largely related to her shame and guilt feelings about the sexual assault. Through the interventions described above, her depression began to subside, and the symptoms receded substantially within approximately a dozen sessions. Her mood lifted, her appetite returned, and her energy level increased. Her posttraumatic stress disorder symptoms were more resilient. I treated these symptoms mostly by talking about her experiences, which functioned as an informal kind of systematic desensitization. We also used coping strategies, such as deep breathing and relaxation. Slowly, her symptoms subsided, but even after 18 months of treatment, there were still occasional nightmares and anxiety symptoms related to the assault. It should be noted that this case was treated prior to the development of eye movement desensitization and reprocessing therapy (Shapiro, 2001) or else that treatment would have been considered. As the depression lifted, we spent more time on interpersonal and characterological issues. Miko had a variety of interpersonal difficulties that continued to motivate her to stay in therapy. Broadly speaking, her relationships were characterized by an excessive need to please coupled with an excessive need for reassurance, which was evidenced primarily in her long-term intimate relationships (e.g., her 2-year relationship with her boyfriend). There was also a pattern of seductiveness, which was more evident in her relationships with me and with strangers. Two interactions were helpful in correcting her internalized schemas. Early in therapy, Miko mentioned that when she had terminated with her prior therapist she brought him a gift and suggested that they begin dating. She told me that the therapist turned her down on the grounds that they were of different religions and there would be problems raising the children. I am not a "blank slate" therapist, so I am certain 'Seppuku is also known as ham kiri, which has been mispronounced "hari kari" in English (Seppuku, n.d.). 184

PERSONAL/TY-G U1DED THERAPY FOR DEPRESSION

that Miko saw the look of astonishment on my face. I informed her that dating relationships between therapist and client, even after termination, were unethical because they typically harmed the client and undid a lot of the good done by therapy. After that, slowly, Miko got less and less dressed up for each session. Her seductiveness (e.g., through body language) also lessened. Confronting her former therapist's inappropriate response had an impact similar to a transference comment, but because it was less direct, it was much easier technically. A second incident occurred in which Miko went to rent a video from a video store. The young man behind the counter told her to take the tape without paying for it, and to just bring it back the next day. I asked Miko for her interpretation of why he had done so. She had not really thought about it. Shrugging her shoulders, she said, "I guess because he's a nice guy." Using a typical cognitive challenge, 1 noted, "Then, do you think he gives free tapes to everyone?" Despite numerous attempts to come up with an alternative hypothesis, Miko was at a loss. Finally, I suggested, "Do you think he may have been attracted to you?" She looked astonished but could think of no other explanation. We were then able to discuss signals that she might be sending out. The conceptual framework was that it is great to be attractive, but it is important to be able to modulate it or else one winds up either starved for affection or with constant unwanted attention. Her attitude changed quickly. Formerly, she saw herself as not pretty enough and, at a deeper level, undesirable, perhaps even unlovable. Her insecurities drove subtle but near constant strivings for approval. Taking seriously the possibility that she was attractive, she consciously used these same skills to attract men. I remember feeling somewhat bad for these young men because Miko was more interested in experimenting with her skills than in having a relationship with them (she had broken up with her boyfriend but was not quite ready to reenter the dating world at that time). I felt relieved that Miko needed only a few weeks of experimenting to see that she was able to attract a great majority of those toward whom she showed interest. Equally if not more important was to find the "off switch," which she also accomplished rather readily. Therapy continued for a number of months thereafter; having gotten past many of her fears and insecurities, she was ready for deeper, more meaningful, more intimate relationships than in the past. We continued to work on helping her to have more complete, assertive, and healthy relationships. At the time of termination, Miko no longer met the criteria for any Axis I or Axis II disorders and was generally functioning in a healthy manner. In sum, I used a series of catalytically sequenced interventions. Cognitive work helped her to get past her initial depressive shame. Further cognitive and behavioral interventions helped her to desensitize from her trauma symptoms. A method akin to analysis of transference, albeit indirect, created a significant correction of her beliefs about the therapeutic relationship and her awareness of boundaries in relationships. The event at the video store HISTRIONIC PERSONALITY DISORDER

185

allowed her to gain insight into the effect of her actions on others. By the end of treatment, she was treating others in a more mature manner, driven by healthy desires for intimacy rather than unhealthy strivings for reassurance. The therapy involved concepts drawn from cognitive, behavioral, interpersonal, and object relations conceptualizations.

SUMMARY AND CONCLUSIONS A variety of interventions can be helpful for depressed individuals with histrionic PD. Cognitive and behavioral interventions can help to reign in their flighty and impulsive proclivities. Goal setting can also be important, because the depression can evaporate temporarily if the client secures a new paramour or finds an exciting new situation, thus leading to premature termination. As illustrated in the case of Miko, psychodynamic factors such as awareness of transference and countertransference feelings can be important in guiding the therapy. The client's interpersonal style and modifications thereof also are crucial in this highly "other-oriented" population. Self-awarenessenhancing interventions, whether through traditional psychological approaches or through specific mindfulness training, are often central to the treatment. These interventions, arranged in a synergistic fashion, can help the person with histrionic PD (or features of the disorder) to alleviate depressive symptoms and live a deeper, more satisfying life. We need more research in a variety of areas. Differences in countertransference reactions of male and female therapists to histrionic clients, especially those who are seductive, would be useful in providing appropriate guidelines for therapists and supervisors. Clinical psychology as a science needs to further investigate the integration of psychotherapeutic approaches, including synergistic and catalytic sequences. Finally, psychodrama may be a particularly useful approach with this population; research in that area would facilitate appropriate treatment and referral as well as enhance awareness of potential pitfalls.

186

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

9 DEPRESSION IN NARCISSISTIC PERSONALITY DISORDER

The nefarious character lago from Shakespeare's Othello demonstrates the devastating effect of unbridled narcissism combined with ruthless sociopathy. In Act 1, Scene 1, lago vents his rage when he is not selected as Othello's officer: But he [Othello], as loving his own pride and purposes, Evades them, with a bombast circumstance Horribly stuff d with epithets of war: And, in conclusion, nonsuits My mediators; for Certes, says he, I have already chose my officer.

And what was he? Forsooth, a great arithmetician, One Michael Cassio, a Florentine, A fellow almost damn'd in a fair wife; That never set a squadron in the field, Nor the division of a battle knows More than a spinster; unless the bookish theoretic, Wherein the toged consuls can propose As masterly as he: mere prattle without practice Is all his soldiership. (Shakespeare, 1972, p. 1171)

187

In this brief passage, lago evidences feelings of entitlement, and projection of his own narcissistic proclivities onto Othello. He denigrates Cassio, in thinly veiled jealousy of the latter's advancement. This specious reasoning— that he, lago, is entitled to promotion because of his superiority—becomes the rationalization for his scheme to advance his position by undermining Othello. PHENOMENOLOGY: THE EXPERIENCE OF NARCISSISTIC PERSONALITY DISORDER Individuals with narcissistic personality disorder (PD) are prototypically haughty, arrogant, and grandiose. They are generally less active than lago, prone to fantasy rather than actual aggression. What is striking about the phenomenology of narcissistic PD is not only how it impacts the person with the disorder but how it impacts others. When teaching, I ask my students to share experiences they have had with people who have characteristics of individuals with each of the PDs. I am consistently struck by the pained look of individuals who are children of narcissistic mothers or fathers. Derogation and consistent inability to ever satisfy the narcissist have been persistent themes. Equally interesting are the numerous stories of individuals who dated people with narcissistic PD just once, disappointed—though amused— at their dates' nonstop focus on themselves, inability to engage in a give-andtake conversation, or the crude and bombastic attempts to impress. Although these individuals were often good-looking, wealthy, well-appointed, and initially intriguing, it soon became evident that having a relationship with one of them would be not only undesirable but insufferable. A colleague of mine (Suzanne Richter, personal communication, February 21, 2002) has provided a striking example of the impact of narcissistic PD on a child, even long into adulthood. The client, a woman in her 30s with a husband and two children, had been recently diagnosed with breast cancer and was preparing to undergo a mastectomy. Although she knew her mother was typically self-involved, she was hoping that her mother would at least be somewhat supportive under such extreme circumstances. When she informed her mother about her diagnosis and impending surgery, her mother responded, "Oh. Anyway, how do you like my dress that I'm wearing to the opera?" and stood up to provide a quick fashion show. The client was crushed. Perhaps the mother believed that she was helping by taking her daughter's mind off such a painful topic. Nonetheless, the empathic failure in this case is remarkable. EPIDEMIOLOGY Estimates indicate that the prevalence of narcissistic PD is less than 1% in the general population and is about 2% to 16% in clinical populations 188

PERSONALITY-G LJIDED THERAPY FOR DEPRESSION

(American Psychiatric Association, ZOOOa). In Pepper et al.'s (1995) dysthymic disorder sample, 4% had narcissistic PD. Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; 6% had narcissistic PD. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 7.8% had narcissistic PD. In another sample of depressed clients, approximately 11% had narcissistic PD (Fava et al., 1995). In a sample of 352 clients with both anxiety and depression, approximately 6% had narcissistic PD as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Thus, in depressed samples, approximately 4% to 11% had narcissistic PD. Zimmerman and CoryelPs (1989) study had no individuals with narcissistic PD; to my knowledge, no studies have assessed the frequency of depression in a sample of individuals with narcissistic PD. WHY DO PEOPLE WITH NARCISSISTIC PERSONALITY DISORDER GET DEPRESSED? Individuals with narcissistic PD often become depressed when their fantasies of unlimited success or admiration from others do not materialize. Noted Millon(1999), Dysthymic disorder is perhaps the most common symptom disorder seen among narcissists. Faced with repeated failures and social humiliations, and unable to find some way of living up to their inflated self-image, narcissists may succumb to uncertainty and dissatisfaction, losing selfconfidence, and convincing themselves that they are, and perhaps have always been, fraudulent and phony, (p. 244) Drawing on psychodynamic and object relations perspectives, O. F. Kernberg (cited in Millon, 1999) described the mixture of fear, rage, and feelings of failure that constitute depression in the individual with narcissistic PD: For them, to accept the breakdown of the illusion of grandiosity means to accept the dangerous, lingering awareness of the depreciated self— the hungry, empty, lonely primitive self surrounded by a world of dangerous, sadistically frustrating and revengeful objects, (p. 244)

Thus narcissistic PD appears to be a factor that increases one's vulnerability to depression. As with antisocial PD, however, it is likely that there is a "reverse exacerbation" of sorts, in that individuals with narcissistic PD and depression are likely more amenable to treatment than those with narcissistic PD alone (see chap. 2, this volume, for a discussion of theoretical models of the relationship between Axis I and Axis II disorders). Depression in narcissistic PD can alternate between being hostile and being withdrawn and sullen. Often individuals compose themselves by returning to grandiose fantasies. If they can attain some level of success, then NARCISSISTIC PERSONALITY DISORDER

189

the depression may dissipate. If not, however, reality continues to hit hard; repeated failures reignite the depression. Tending to blame others, persons with narcissistic PD may at times appear paranoid as they attempt to find an excuse for failing to live up to their own virtually unreachable expectations.

HOW A PERSON BECOMES AND REMAINS NARCISSISTIC: THEORIES OF NARCISSISTIC PERSONALITY DISORDER Biological Factors To my knowledge, there have been no studies of the neurobiology of grandiosity, arrogance, lack of empathy, or other narcissistic traits.1 Millon (1996) noted that the biological mechanisms of narcissistic PD were not known. Other factors, such as heritability and medications, have received at least some attention. Heritability

As with other PDs, narcissistic PD appears to be moderately heritable. In their study of the heritability of PDs in children and adolescents, Coolidge, Thede, and Jang (2001) found that narcissistic PD had a heritability of 66%. Livesley, Jang, and Vernon's (1998) twin study found that narcissism had a heritability of 43.6%. Medications Almost no studies have assessed the use of medications for individuals with narcissistic PD. The Ekselius and von Knorring (1998) study reviewed in chapter 1 of this volume included 37 individuals with narcissistic PD. Results were generally discouraging. Neither sertraline nor citalopram were associated with statistically significant reductions in diagnosed rates of narcissistic PD. The citalopram group decreased by a mean of 0.5 criterion preto posttreatment, which was significant; the sertraline group, however, decreased by a mean of only 0.2 criterion, which was nonsignificant. D. W. Black, Monahan, Wesner, Gabel, and Bowers (1996) found that narcissistic traits were not impacted by fluvoxamine, relative to placebo. Given the extremely limited available data, it is appropriate to consider the hypotheses developed by Joseph (1997) on the basis of his clinical experience. He argued that the features of narcissistic PD, such as grandiosity, feelings of entitlement, and arrogance, can be conceptualized as symptoms of hypomania and thus treated with medications such as lithium and 'On the basis of her clinical experience, Mary Francis Schneider (personal communication, January 3, 2006) has speculated that the empathic failure associated with narcissistic PD falls along the autistic spectrum. Although there is no empirical support for her theory at this time, I believe it is worthy of investigation.

190

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

anticonvulsants (e.g., carbamazepine or valproate). To the extent that persons with narcissistic PD show paranoia (e.g., feeling envious and believing others are envious of them), Joseph suggested that antipsychotic medications such as risperidone, olanzapine, or sertindole are efficacious. When the individual with narcissistic PD becomes depressed, Joseph recommended mood stabilizers, selective serotonin reuptake inhibitors, or a combination thereof. It is not clear from a theoretical standpoint that manic grandiosity and narcissistic grandiosity are linked. According to Millon's (1996) theory, most individuals with narcissistic PD are passive and calm unless insulted. Biological research would help to clarify the neuroanatomical and neurochemical correlates of narcissistic PD, leading to potential medication strategies. Whether confirming Joseph's (1997) hypotheses or evaluating new ones, randomized clinical trials are necessary to verify the effectiveness of medication treatment for symptoms of narcissistic PD.

Psychological Factors Within the biopsychosocial model (Millon, 1969), psychological considerations fall midway between the "micro" level biological factors (which involve considerations at the molecular level) and the "macro" level social factors (which involve interactions of entire cultures, often including hundreds of millions of people). The psychological approaches reviewed in the following sections attend to behavioral, cognitive, affective, unconscious, and interpersonal aspects of the person's functioning. Millon's Theory Within his theoretical framework, Millon considered the narcissist to be the passive, self-oriented type. Narcissists are variable along the painpleasure dimension, which is thus not entered specifically into the formulation of the personality. They are passive in that they expect to have their desires met without having to put forth any effort. The self-orientation indicates an independent style, not relying on others for gratification. Millon (1981) described the characteristics as follows: Narcissism signifies that these individuals overvalue their personal worth, direct their affections toward themselves rather than others, and expect that others will not only recognize but cater to the high esteem in which narcissists hold themselves. . . . Narcissistic individuals are benignly arrogant . . . they operate on the fantastic assumption that their mere desire is justification for possessing whatever they seek. (pp. 158-159)

It is Millon's belief that narcissism results from early and excessive positive regard from the child's parents. The parents view the child as marvelolusly superior and talented, regardless of his or her actual accomplishments. NARCISSISTIC PERSONALITY DISORDER

191

This aggrandizing attitude is internalized—learned—by the future narcissist. Further, their parents' doting models the subservience that persons with narcissistic PD come to expect from all with whom they interact (Millon, 1981). Millon's (1981) view is in marked contrast to analytic viewpoints exemplified by O. F. Kernberg (1970/1986b) and Kohut (1971). Kernberg and Kohut saw narcissism as a defense against underlying feelings of worthlessness, emptiness, and boredom. One of Millon's subtypes, the compensatory, appears to be similar to the analytic description of narcissism. This subtype is a mixture of narcissistic and passive-aggressive/negativistic features (Bockian, 1990). Millon's domain-level descriptions of narcissistic PD are given in Appendix B. Of the domains, the exploitive interpersonal conduct and admirable self-image are the most salient. Cognitive-Behavioral Conceptualization and Interventions Individuals with narcissistic PD are prone to thoughts such as "I am superior" and "Others should cater to my needs." Depending on their personal history, their core beliefs tend to vary. Millon's (1981) prototype would be an individual who has a deep well of parental overvaluation on which to draw. For such individuals, the core beliefs match the automatic thoughts, and they genuinely believe they are superior; in the case of persons with narcissistic PD and depression, they are typically perplexed by reality's failure to demonstrate this obvious truth. The prototype is someone born to royalty, who would, naturally, expect to be treated deferentially by his or her subjects. Individuals who fit in with modern psychodynamic formulations, such as those of O. F. Kernberg (1970/1986b) and Kohut (1971), would have substantially different profiles. Although superficially grandiose, underneath they harbor beliefs about inadequacy and worthlessness. Exhibit 9.1 outlines the thought processes of the two basic subgroups of narcissists. What is remarkable is that individuals with such different experiential histories can have such a similar superficial manifestation, yet it is clear from case material that this is in fact the empirical reality. Although not present in conscious awareness, for insecure narcissists the fear is that they are imposters and are not truly superior; this trepidation often lurks in the shadows of their awareness. A. T. Beck, Freeman, and Davis (2004) noted that there are three key targets in treating someone with narcissistic PD: (a) increasing goal attainment and exploring the meaning of success; (b) improving empathy and awareness of others' rights; and (c) enhancing self-esteem and beliefs about selfworth. Breaking down grandiose expectations into more achievable steps can be extremely useful in treating the person with narcissistic PD. Dysfunctional thought records can be used to challenge all-or-none thinking such as, "Unless I'm the star of the show I'm a total failure." Problem-solving discussions can help to undo inappropriate behavior, by, for example, replacing fantasy with concrete steps toward goal attainment. Beliefs about self can be gently and supportively challenged when there is sufficient rapport; for example, 192

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

EXHIBIT 9.1 Conceptualization of Narcissistic Personality Disorder: A Comparison of Millon (1981, 1996) and O. F. Kernberg (1986b, 1986c) Millonian narcissist (secure narcissist)

Analytic narcissist (O. F. Kernberg; Kohut, 1971; insecure narcissist)

Core belief I am perfect I am great I am superior to others

I am worthless I am an imposter Experiential history

Excessive praise, especially for aspects Being put down, neglected of the self that do not require effort (e.g., praise for being handsome, pretty, or cute) High expectations Intermediate beliefs If someone stands in my way, he should be destroyed. If others don't recognize my greatness, it is because they are fools.

I'll show them. If I make an effort and fail, that would be horrible, If I am not superior, then I'm horrible, because the average person is a loser. If others don't recognize my superiority, then they are idiots.

Automatic thoughts Putting forth effort is beneath me. Others should recognize my superiority and reward me for it.

I am better than any of these people. They are a bunch of stupid losers,

the strategy of emphasizing what might be gained by a more accepting stance toward criticism can facilitate growth (A. T. Beck et al., 2004). A. T. Beck and his associates (A. T. Beck et al., 2004; A. T. Beck & Freeman, 1990) recommended some alternative beliefs that can be used as goals or benchmarks for the individual with narcissistic PD. Reframing grandiose narcissistic beliefs into more realistic ones can be extremely beneficial—for example, "I can be ordinary and be happy"; "One can be human, just like everyone else, and still be special"; "Relationships are experiences, not status symbols" (A. T. Beck et al., 2004, p. 266); and "To let the evaluations of others control my moods makes me dependent on them and out of control" (A. T. Beck & Freeman, 1990, p. 249). Other techniques can also be aimed at the various difficulties that constitute narcissistic PD. For example, hypersensitivity to criticism (that triggers narcissistic rage) can be treated with systematic sensitization. Fantasies of unlimited success can be altered using imagery work; for example, a fanNARCISSISTJC PERSONALITY DISORDER

J 93

tasy of being a star of a Broadway show can be replaced with an image of starring (or even having a secondary role) in a local theater production. Such images should focus on deriving pleasure from the activity itself, not only from the applause or the "glory." Finally, extensive use of role play and imaginal work can help the client to improve his or her empathic capabilities (A. T. Beck & Freeman, 1990). Psychodynamic Therapy Underlying narcissistic grandiosity, according to O. F. Kernberg (1970/ 1986b), is a defect of early object relations. He argued that severe narcissism does not reflect simply a fixation in early narcissistic stages of development and a simple lack of the normal course of development toward object love but that it is characterized by the simultaneous development of pathological forms of self-love and pathological forms of object love (O. F. Kernberg, 1970/1986b, p. 216). As shall be seen later, this is exactly opposite Kohut's (1971) argument that narcissistic disorders are indeed fixations in a narcissistic period. O. F. Kernberg (1970/1986b) asserted that what happens in the case of the narcissist is a "refusion" of the self and the object after the establishment of functional ego boundaries. The ideal self, ideal object, and actual self are fused into one internalized image. Thus, according to Kernberg, It is as if they [narcissists] were saying, "I do not need to fear that I will be rejected for not living up to the ideal of myself which alone makes it possible for me to be loved by the ideal person I imagine would love me. That ideal person and my ideal image of that person and my real self are all one, and better than the ideal person whom I wanted to love me, so that I do not need anybody else any more." In other words, the normal tension between actual self on the one hand, and ideal self and ideal object on the other, is eliminated by the building up of an inflated self concept within which the actual self and the ideal self and ideal object are confused. (O. F. Kernberg, 1970/1986b, p. 217) O. F. Kernberg (1970/1986b) also stated that narcissists very often have backgrounds in which the parental figures are chronically cold with underlying aggressive feelings. The child may be used to fulfill the parents' narcissistic ambitions to be brilliant or great. The child often occupies a critical role in such families, being either an only child or considered to be one with special talents or intelligence. The situation thus fosters a need to defend against envy to live up to high expectations. Once set into motion—once the real and idealized self and object images have been fused—the pattern becomes "extremely effective in perpetuating a vicious circle of self-admiration, depreciation of others, and eliminating all actual dependency" (O. F. Kernberg, 1970/1986b, p. 220). O. F. Kernberg (1970/1986b) saw the narcissist as feeling deeply rooted emptiness, rage, and fear as a consequence of the pathological fusion of self

194

PERSONALITY-G L/1DED THERAPY FOR DEPRESSION

and object images. The destruction of the external object image entails the destruction of appropriate self images, leaving a feeling of emptiness. The inability to experience others as real and whole objects implies inadequate mirroring of the grandiose fantasies of the narcissist; in order to be admired, one must have relationships with real people. Idealized people, on whom these patients seem to "depend," regularly turn out to be projections of their own aggrandized self concept... . His attitude toward others is either deprecatory—he has extracted all he needs and tosses them aside—or fearful—others may attack, exploit, and force him to submit to them. At the bottom of this dichotomy lies a still deeper image of the relationship with external objects, precisely the one against which the patient has erected all these other pathological structures. It is the image of a hungry, enraged, empty self, full of impotent anger at being frustrated, and fearful of a world which seems as hateful and revengeful as the patient himself. (O. F. Kernberg, 1970/1986b, pp. 218219) Heinz Kohut's (1971) theory of narcissism is based on his clinical observations of numerous narcissistic clients. His theory differs from the others in that he saw narcissistic needs and endeavors as constituting a separate line of development, an essential and normal part of the growth process. Pathological narcissism, then, is a fixation to a point of development; the phaseappropriate conflicts, as with any fixation, remain unresolved and are thus neurotically acted out or repeated (Kohut, 1971; see also O. F. Kernberg, 1986a, 1986b, 1986c). The trauma that causes the fixation is generated by the parents: As can be regularly ascertained, the essential genetic trauma is grounded in the parents' own narcissistic fixations, and the parent's narcissistic needs contribute decisively to the child's remaining enmeshed within the narcissistic web of the parent's personality . .. (Kohut, 1983, p. 186) Kohut (1971) refused to actually describe behavioral and diagnostic attributes of narcissists. He maintained that the only reliable criterion for diagnosis is the spontaneous emergence of one of the narcissistic transferences. Others, however, have gleaned characteristics from throughout Kohut's work and have suggested the following criteria: Sexually, they may report perverse fantasies or lack of interest in sex; socially, they may experience work inhibitions, difficulty in forming and maintaining relationships, or delinquent activities; and personally, they may demonstrate a lack of humor, little empathy for others' needs and feelings, pathologic lying, or hypochondriacal preoccupations.... Reactive increase in grandiosity because of perceived injury to self-esteem may appear in increased coldness, self-consciousness, stilted speech, and even hypomanic-like episodes. (Akhtar & Thomson, 1982, p. 14)

NARCISSISTIC PERSONALITY DISORDER

195

For Kohut, however, the critical feature was the type of transference manifest within therapy. He stated that there are two basic kinds of transferences that indicate narcissistic disorders (see Kohut, 1971). The first is the idealizing transference, in which the client sees the therapist as all good and perfect, re-creating the relationship with the idealized parental "imago"— the unrealistic image of perfection through which the infant or young child views his or her parents. The second kind of transference, or mirror transference, is the reactivation of the grandiose self, that is, the undifferentiated omnipotence of infancy. The mirror transference constitutes the therapeutic revival of the developmental stage in which the child attempts to retain a part of the original, all-embracing narcissism by concentrating perfection and power upon a grandiose self and by assigning all imperfections to the outside. (Kohut, 1983, pp. 187-188)

There are three specific types of mirror transference: (a) merger (through the extension of the grandiose self); (b) alter-ego or twinship; and (c) the mirror transference in the narrower sense, which is the one most often referred to by Kohut. In the merger transference, the analyst is not experienced as a separate entity but rather as a part of the analysand. This notion is similar to Kernbergian notions of the transference, and in fact a case of O. F. Kernberg's (1986c) illustrates the phenomenon dramatically. Kernberg had pointed out some disparities between the content of the client's discussions and his tone of voice. "The patient first had a startled reaction, and after I finished talking, he said that he had not been able to listen attentively to what 1 was saying, but that he had all of a sudden become aware of my presence" (O. F. Kernberg, 1986c, p. 279). The failure to even acknowledge the existence of others except perhaps to bolster one's own self-esteem is a highly narcissistic reaction. In the twinship transference, the analysand sees the analyst as a separate person but one very much like him- or herself. Meissner, reviewing Kohut, stated, At a somewhat less primitive level of organization [than the merger transference], the activation of the grandiose self leads to the experiencing of the narcissistic object as similar to, and to that extent a reflection of, the grandiose self. In this variant, the object as such is preserved but is modified by the subject's perception of it to suit his narcissistic needs. This form of transference is referred to as alter-ego or twinship transference. Clinically, dreams and fantasies referring to such alter-ego or twinship relationship with the analyst may be explicit. (Meissner, 1986, p. 417)

This is less archaic than the merger transference, but is still a primitive way of relating; it is rarely seen, even among narcissists. The mirror transference in the narrower sense is the most thoroughly discussed by Kohut (1971) and thus presumably the most common or impor196

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

tant. In this case the analyst is experienced clearly as a separate person but only considered important when he or she is "mirroring," or confirming, the analysand's grandiose notions of him- or herself. It is the reenactment of "the gleam in the mother's eye, which mirrors the child's exhibitionistic display" (Kohut, 1971, p. 116). It is through the re-creation of this critical phase of development that Kohut believed the corrective reconstruction process can take place. Narcissists do have relations with objects. However, according to Kohut (1971), the objects only have significance insofar as they are seen as extensions of the self. Kohut thus labeled these "self-objects," inasmuch as the self and the object are largely fused. Obviously, seeing others as a part of oneself involves a great deal of denial or distortion, thus impairing the reality-testing capabilities of the individual. Family Systems

Couples in which both partners have narcissistic PD have unique vulnerabilities that can be addressed in couples therapy. Kalogjera et al. (1998) described an approach based on Kohut's self psychology. In broad terms, the problem of the narcissistic couple is that they fail to meet each other's selfobject needs, thus reactivating old wounds from childhood. Mirroring selfobject needs include the need for healthy attention from a significant other, such as empathy and attentive listening. Twinship self-object needs include shared interests and the need for mutually gratifying physical contact. Idealizing self-object needs include the desire for respect and the capacity to see good and wonderful qualities in the other person. However, individuals with narcissistic PD tend to be self-absorbed and provide insufficiently for the partner's self-object needs in all three domains. When injured, each withdraws or rages at the other, perpetuating a cycle of wounding and of empathic failure. Kalogjera et al. illustrated the phenomenon with the following vignette: In a conjoint marital session, Bob expressed his feelings of disappointment and hurt that his father did not accept his advice regarding a legal matter. This was particularly painful to Bob, in light of the fact that he is an expert in this field. This is one of the few instances in which Bob was able to be open regarding his feelings about his family. He was expecting an empathic and validating response from Kathy. Instead, she looked at him in an icy manner and, in a cold tone, stated, "I don't think that should be affecting you anymore." At that point, Bob became visibly angry; he turned toward the therapist and, in an agitated voice, shouted, "Would you want to be married to a woman like this?" (p. 220)

Correcting the problem in relatedness requires that the therapist address, and show the couple how to redress, multiple levels of empathic failure simultaneously; in addition, it is necessary for the therapist to reenerNARCISSISTIC PERSONALITY DISORDER

197

gize the feelings of hope and optimism that formed the initial attraction and idealization of the couple. Over time, this idealization is often worn away (de-idealization), and desires for reparations emerge in their stead (the curative fantasy). As often happens in these cases, both members of the couple are wounded simultaneously. The therapist must address their needs without siding with either member of the couple, or, more accurately, siding with both equally and simultaneously. Kalogjera et al.'s (1998) case illustration is highly instructive: Therapist (T): Bob, you felt very hurt . . . you very much wanted Kathy to know how you felt about your painful interactions [rejection] with your father. You hoped Kathy would understand your pain and help you deal with it. (The therapist empathically expresses the identification of the narcissistic injury, the unfulfilled selfobject needs for mirroring and twinship, and recognition of curative fantasy.) Bob: T:

Kath^:

Uhhuh (visible diminution of signs of anger). Kathy, for you Bob seemed preoccupied with his relationship with his father ... it felt as if his father was more important to him than you and your marriage. (Again, the therapist empathzcalfy identifies narcissistic injury and unfulfilled selfobject needs for mirroring and twinship . . .) Yeh (she nods her agreement), (p. 231)

Note how the therapist simultaneously addressed both members of the couple to prevent further narcissistic wounding and to promote an alliance. The therapy continued: T:

198

Bob and Kathy (addressing both together, to provide mirroring for them as a couple and twinship by joining them, thereby enhancing cohesion of the marital bond), due to feeling deeply hurt, you have not been able to understand and meet each other's needs (empathic attunement and identification of selfobject failure). You did not feel safe, and you both withdrew from each other (identification of the defensive reaction to fear of narcissistic injury). Since you perceived each other as uncaring and blaming, a lot of resentment has built up in both of you (identification of a source of de-idealization and subsequent development of narcissistic rage). The risk for both of you was being hurt and yet not being heard again (repetition of traumatization from childhood mirroring selfobject failures). As a consequence it became very difficult to invest emotionally in your partner and in your future (identification of destruction of curative fantasy). Your marriage became less important, and you started to have doubts about your commitment to i t . . . you both withdrew from each other (identifica-

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

tion of idealizing self object failure and further weakening of the curative fantasy, and defensive withdrawal from the relationship), (p. 231) After approximately 18 months of treatment, the couple was functioning much better. They were freer and more open and loving with one another and laughed together more, and their sex life became satisfying again. They had worked through many of their hurt feelings, and, in the process, each member of the couple experienced a dramatic reduction in narcissistic symptoms. L. S. Benjamin (1996a) recommended a similar approach. Couples work can facilitate recognition of the narcissistic pattern, which can be a tricky balancing act; it would be easy to fall into a position that would be seen as blaming one member of the couple or the other. For example, noting, "You tried to do something special and felt unappreciated by her" feeds the narcissistic husband by making his wife the villain, whereas stating, "Each person in the couple contributes to the problem; let's look at what each of you is doing" fails to validate the narcissistic client and is too far from his worldview. Stating instead, for example, "You have been trying to make things work well, and you feel just devastated to hear that they aren't going as perfectly as you thought" allows the recognition of problematic aspects of the narcissistic pattern, positively framed, and avoids blame. Individuals with narcissistic PD also often pair with individuals with dependent PD. For further discussion of the dependent-narcissistic couple, see chapter 12 of this volume.

COUNTERTRANSFERENCE Therapists frequently have difficult emotional reactions when treating individuals with narcissistic PD. Therapists have narcissistic needs, among them the need to be acknowledged by the client, perhaps even appreciated, and another the need to see the client make progress to validate our perceptions of ourselves as competent therapists (Ivey, 1995; Kohut, 1971). Clients with narcissistic PD can be maximally frustrating to both of those needs. According to psychodynamic theory, their psychic structure is designed specifically to avoid acknowledging the contribution of others and to maintain the fantasy that they are completely self-sufficient. The withdrawal of the client leads to feelings of boredom, and his or her grandiosity pulls for feelings of anger and punitiveness. As was discussed in the chapter on antisocial PD, the therapist will be drawn to reject clients when they act in an infantile manner (e.g., relentlessly demanding attention and admiration like a 2-yearold). Analytically oriented thinkers relate this to the internal developmental process of the therapist, who rejected (or, more technically, whose superego rejected) the infantile self as part of maturation (Cooper, 1959/1986); NARCISSISTIC PERSONALITY DISORDER

199

cognitively oriented theorists note the disappointment of the therapist whose patient does not change and who attributes the problem to his own incompetence (A. T. Beck et al., 2004). Ironically, the client's defensive structure pulls for anger, rejection, and neglect, precisely the situations and feelings they were designed to avoid. It is natural, though countertherapeutic, for the therapist to reject the client in kind (Cooper, 1959/1986; O. F. Kernberg, 1970/1986b, 1974/1986c; Kohut, 1971). Similarly, the client's arrogant, haughty attitudes and criticism of the therapist can interfere with the therapist developing empathy for the client (A. T. Beck et al., 2004). Such emotions are difficult to handle and are at odds with the self-concept of most therapists. Conversely, the therapist must be careful not to be drawn into the client's aggrandizing comments (e.g., compliments and flattery), which can lead to collusion to avoid change or be a cover for the client's covetousness of the therapist's positive qualities or possessions (A. T. Beck et al., 2004). Empirical studies support the kinds of reactions that have been reported in the literature. Betan, Heim, Conklin, and Westen (2005) collected a countertransference questionnaire from 181 clinicians; the instructions were to include clients that they had seen for at least eight sessions. Thirteen of the clients who were rated had narcissistic PD. The authors noted, "Clinicians reported feeling anger, resentment and dread in working with narcissistic personality disorder patients; feeling devalued and criticized by the patient; and finding themselves distracted, avoidant, and wishing to terminate treatment" (Betan et al., 2005, p. 894). A study of responses to a filmed vignette of an individual with narcissistic PD indicated that therapist trainees were most likely to feel fear (indicated by response choices fearful, guarded, alarmed, and afraid) and anger (angry, frustrated); other likely emotions were indicated by single items (curious, pity, sad, dislike). Informal discussions with participants indicated that the fear was that the client would either verbally attack the therapist or "lose it" in a fit of rage, and anger was generated by the client's supercilious and devaluing attitude (Bockian, 2002a; see chap. 1 for further details of this study). I recall experiencing several such feelings and entrapments with a person I treated early in my training. The client was a law student and thus had access to the counseling center where I was an extern. Strikingly handsome, he was able to quickly attract and seduce women; however, there was one woman whom he desired but with whom he had numerous get-togethers and breakups. He was genuinely perplexed by his inability to maintain a relationship with her, or, more accurately, by her lack of sustained interest in him. During one of our sessions, he said to me, "You don't say very much." I made some neutral comment, such as "Tell me more about that." He responded, "If I had to pay you, I would just set up a mirror and talk to myself." I felt wounded by his devaluing comment and, internally, withdrew into intellectualization ("My, how interesting, is this a mirroring transference?"). I then discussed 200

PERSONALITY-G U1DED THERAPY FOR DEPRESSION

with him my role in therapy and made some efforts to correct what I am certain were distortions on his part. The session felt empty and unsatisfying. Many years later, in preparing a lecture on narcissistic PD, I had a fantasy of a conversation that might have been: Client:

If I had to pay you, I would just set up a mirror and talk to myself.

Therapist:

I'm wondering, did you consider how I might feel when you said that?

Client:

Isn't that your job? If you can't take it, you shouldn't be a counselor.

Therapist:

You're a law student. It was a yes or no question; please just answer yes or no. Did you consider how I might feel when you made your comment?

Client: Therapist:

No. Do you think that might have something to do with the difficulties you are having with your girlfriend?

Thus one possible approach to countertransference is to use it as a sensitive antenna to identify the transference—in this case, devaluation tinged with entitlement and aggression. What has happened in the here and now can then be related to the client's presenting complaint. If the client's presenting problem is relationship oriented—and it often is—then when you as therapist feel devalued, it is an opportunity to share how, within the context of the client's goals, the comment is devaluing. Such "transference comments" are likely to be effective only if a therapeutic relationship has been established in which the client has felt validated and understood, at least to some degree.

SOCIAL CONSIDERATIONS AND DIVERSITY As noted in chapter 3, features of antisocial and narcissistic PDs were induced in randomly selected college-aged men in the famous Stanford prison experiment (Haney, Banks, & Zimbardo, 1973). Collins (1998) extended this finding by having college student participants rate behaviors as either masculine or feminine; consistently, the guard behaviors (dominance, aggression) were rated as masculine, whereas prisoner behaviors (depression, anxiety) were rated as feminine. Because all of the participants were the same gender and were randomly assigned, the only plausible explanation for the differences in behavior was social role. Social dominance, then, tends to elicit arrogance and oppressive behavior, whereas social status inferiority elicits feelings of helplessness, depression, and anxiety. Thus, one explanation of NARCISSISTIC PERSONALITY DISORDER

201

the gender gap in narcissistic PD is the impact of male privilege and patriarchy on mental functioning. Anthropologist Richard Castillo (1997) would agree with such an interpretation. In discussing gender differences in narcissistic PD, he observed, The symptoms of narcissistic personality disorder appear to be more likely to occur in societies that are hierarchical and egocentric, for example, the United States. It is likely that persons with this disorder will belong to one or more dominant groups in social hierarchies, (p 106)

He further noted that the disorder is less likely to occur in egalitarian cultures, such as the Senoi Temiar of Malaysia, and to be adaptive in extremely egocentric cultures such as the Swat Putkhtun of northern Pakistan. For the typical clinician in the United States, the major subcultures of interest are Euro-American, Asian, Hispanic, Native American, and African American. It is likely that more sociocentric cultures such as those of Japan and China are less likely to produce narcissistic pathology. Hierarchies within Hindu culture may produce behaviors that appear to be narcissistic but are considered acceptable within the culture (e.g., the superior behavior of the Brahman relative to the obsequious behavior of an untouchable). Machismo in Hispanic culture may also produce "false positives" for narcissistic PD in what are considered acceptable behaviors within the culture. White EuroAmericans may be more prone to take privilege for granted and to not recognize that their expectations may be considered excessive from the standpoint of other, less empowered groups (Castillo, 1997). STRENGTHS OF PERSONS WITH NARCISSISTIC PERSONALITY DISORDER Traits that are seen in mild, subclinical, or normal-range narcissism entail many features that are highly valued in Western culture. Confidence is valuable in nearly any circumstance. Most individuals who have accomplished great achievements have a belief in themselves that is along the dimension of narcissistic PD. The belief that one's ideas are sufficiently valuable that others should invest time, energy, or money in supporting their actualization is a prerequisite to accomplishment. To a certain degree, what separates healthy self-valuation from pathological narcissism is the understanding that ordinarily, regardless of one's ability, one must work hard to achieve one's goals (Bockian, 1990). TREATMENT PLANNING: SYNERGISTIC TREATMENT Because the person with narcissistic PD is considered the passiveindependent type, the logical goal is to balance the polarities by helping the 202

PERSONALITY-G U1DED THERAPY FOR DEPRESSION

EXHIBIT 9.2 Therapeutic Strategies and Tactics for the Prototypal Narcissistic Personality STRATEGIC GOALS Balance Polarities Stimulate active-modifying Encourage other focus Counter Perpetuations Undo insubstantial illusions Acquire discipline and self-controls Reduce social inconsiderations TACTICAL MODALITIES Moderate admirable self-image Dismantle interpersonal exploitation Control haughty behavior Diminish expansive cognitions Note. From Personality-Guided Therapy (p. 443), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

client to become more active and more attached to others. Several proclivities lead to the perpetuation of the narcissistic pattern; these tendencies must be undermined in order to make progress. The client's illusions of superiority interfere with actual efforts to accomplish anything. Failure to gain desperately desired admiration because of genuine lack of accomplishment or underachievement leads to further fantasy rather than redoubled efforts; this cycle leads to depression and other mental deterioration. Impulsive rage alienates these individuals from others, and thus from the support that may help them to reach their goals. Another mechanism of social alienation is withdrawal into fantasies of unlimited success. Once social isolation occurs, the feedback necessary to help ground the individual in reality is undermined, and he or she begins to slide increasingly down the slippery slope of illusion, delusion, and self-boosting fantasy. Thus, therapy should be geared to reduce illusions of superiority, increase the person's self-control, and decrease social alienation (see Exhibit 9.2). The long-term goals for depressed individuals with narcissistic PD, then, include encouraging them to set goals; increase activity level; and decrease arrogance, entitlement, and exploitation and helping them to gain control over their rage and to recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma 6k Peterson, 1999). The most effective treatment arranges catalytic sequences that synergize and build on one another. For the client with narcissistic PD and depression, motivation will often be problematic; thus the best initial interventions will NARCISSISTIC PERSONALITY DISORDER

203

be those that offer the best hope of rapid change. Alternately querulous, irritable, and showing bravado, people who have both depression and narcissistic PD will typically first respond best to a humanistic approach (validation) to establish a strong working alliance. A delicate balance often arises between "feeding the narcissism" and providing appropriate validation. Reflecting back true statements that do not directly confirm the more grandiose claims works well (e.g., "It sounds like you have a number of accomplishments of which to be proud"), as does validating the feelings (e.g., "It must be very painful to feel so misunderstood so often"). Then, as recommended by Millon (1999), one may explore the client's developmental history with the goal of gaining insight into the meaning of the client's behaviors and attitudes. Cognitive and behavioral interventions can then help to functionally improve behavior and mood. If the depression is not so severe that it precludes psychotherapeutic improvement, then it is best to wait for some psychological improvements to occur before introducing psychopharmacological interventions; individuals with narcissistic PD can lose motivation to make psychological changes once the immediate crisis is resolved. Some, however, are more connected to the psychotherapy; the opportunity to have undivided attention from another person is often appealing to the individual with narcissistic PD. In that regard, long-term psychodynamic or psychoanalytic therapy can be comfortably accepted. Family therapy can help the individual to correct patterns of exploitiveness and derogatory communication in marital and parent-child relationships. Group therapy can be extremely helpful in correcting interpersonal patterns, though there are two cautions: The narcissistic client often flees in the face of confrontations that threaten to explode his or her illusions, and there is a risk of the person becoming a monopolizer in the group. If those two factors can be managed, then prospects are reasonably good. Ultimately, if it is impossible to challenge the illusions, then the therapy has failed, so it is incumbent on the group therapist to find a balance between support and confrontation within the group.

CASE EXAMPLE: TOMAS At the beginning of therapy, Tomas, a Hispanic man, was 38 years old. At that time, he was married and had two children, ages 6 and 9. Tomas had experienced homosexual urges since childhood. He began to visit pornographic Web sites, and finally, he began to have affairs with men. He was caught, which precipitated a divorce; shortly thereafter he began therapy. At the time that he presented for treatment, he was depressed, anxious, and suicidal. Early in the treatment, Tomas wondered if he might be narcissistic. Reviewing the criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, ZOOOa) with 204

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

the therapist, Mark Johns, in a collaborative fashion allowed the client to recognize that the label fit. Recognition of the narcissistic pattern and insights into its nature and origins became a key feature of treatment. Tomas was raised by two alcoholic parents. Although affectionate when sober, they were often emotionally neglectful. Forced to rely on himself, he always yearned for someone to fill his emotional hunger, to provide for his natural needs for mirroring and validation, and to care for him. His selfesteem was badly damaged, and he fit best into the "compensatory narcissist" conceptualization; his attempts at self-inflation were an effort to hide his underlying doubts and fears about his worthiness. He became preoccupied with fantasies of ideal love and supreme beauty and was consumed by concerns about his looks, weight, attractiveness to others and his desperate search for the ideal partner. Initially, Tomas believed that his attraction to men was temporary, a phase or just an expression of curiosity. As it became clearer that his primary sexual orientation was toward men, it precipitated a personal crisis. He felt dirty, guilty, and shameful. Tomas had remarkably little empathy for his wife's position. His main focus was on his own suffering, and he was perplexed that she was not supportive and understanding of the deep pain he was experiencing and had been experiencing throughout most of his life. Once divorced, he would share with her the intimate details of his sexual liaisons. His empathy was so poor that he did not fathom how hurtful this might be to her. Although his actions may have appeared to have a sadistic tinge, he did not appear to get satisfaction from hurting her or to be attempting to control her through intimidation. In part, his "sharing" was driven by a self-focus on his own pain without adequate consideration of his ex-wife's needs. Despite the circumstances of their relationship, he felt entitled to her support. Ironically, although he had rejected his ex-wife, he felt even more rejected by her. He was covetous of her admiration, and his projection of his own negative feelings about himself led him to attempt to prove to her that he was attractive and desirable by boasting, if you will, about his relationships. His difficulties with empathy extended to his relationship with his children as well. Although he cared about them, their genuine needs were trumped by his concern for his image; he was primarily concerned about how his actions would make him look in the eyes of others or about how his children's behaviors would reflect on him. The initial phase of therapy focused on validating Tomas's experience. The process of coming out and developing a gay identity is typically fraught with difficulties. Dr. Johns focused on the struggles that the client experienced and on his personal sense of pain. Tomas was taught mindfulness meditation, emotional regulation techniques, and distress tolerance (Kabat-Zinn, 1990; Linehan, 1993) as ways of coping with his pain. Like many individuals with narcissistic PD, Tomas initially had poor boundaries. He would call Dr. Johns very frequently, sometimes more than once per day, primarily to reNARCISSISTIC PERSONALITY DISORDER

205

lieve his anxiety. Dr. Johns used the model from dialectical behavior therapy (Linehan, 1993), in which phone calls could be used to reinforce coping skills, but if the phone call became lengthy, then an additional session was scheduled. This model worked well, and between-session phone calls gradually diminished over time. Once rapport had been adequately established, cognitive techniques (A. T. Beck et al., 2004) were used to correct Tomas's cognitive errors, particularly his black-and-white thinking. There was a powerful pull for Dr. Johns to align with the wife and children and immediately push for the client to have greater empathy. To do so too early would have been a therapeutic error. The therapeutic relationship had to be solid before such work could be undertaken. Nonetheless, mindfulness meditation training (which has been shown to increase empathy levels) enhanced Dr. Johns's ability to sit with his own pain and thereby be more available to listen to Tomas. Later in therapy, after Tomas comprehended clearly that Dr. Johns understood and validated him and there was a strong therapeutic bond, direct interventions to help the client to put himself in his wife's and children's shoes was undertaken. There was progress in that area, which, though extremely slow, was a positive development for the client. The main breakthrough in the case came when Dr. Johns suggested the use of the empty chair technique to help Tomas resolve the internalized split between his idealized and devalued self. Dr. Johns instructed the client to sit in a chair and have the "good self" talk to the "bad self," with the encouragement that they somehow find a way to come to terms with one another and develop a working relationship with each other. The good self was the straight, married-with-two-children, "perfect" (stereotypic) American male. The bad self was the gay, porn-watching adulterer. As the conversation evolved between the two, it became clear that the good self was also overbearing, judgmental, rigid, and insufferable, a manifestation of a domineering superego. The bad self was gentle, vulnerable, fallible but forgivable, and tender (and considerably more fun and likable). Apparently, the bad self was not all bad, nor was the good self all good. Given that the underlying need was to be loved (for which the need to be admired had been substituted but could never really fill the void), the good self would have to come to terms with the bad self. The bad self was the lovable one and offered the best hope of salvation. Much of the client's depression was a function of his internalized homophobia. Raised Catholic, in a culture that promoted strong, stereotypically masculine roles, he had intense negative images of homosexuality. Being gay was associated with sinfulness, unmanliness, and worthlessness. As he developed a more affirmative and increasingly integrated gay identity, his depression lessened. Countertransferentially, Dr. Johns often experienced feelings of irritation and frustration and, at times, exasperation. Tomas tried to build himself up at the expense of others, which went against Dr. Johns's values. The de206

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

valuation was at times directed at Dr. Johns, which elicited anger. Dr. Johns would attend closely to his own emotional reactions and then confront Tomas in the here and now, thus helping him to recognize how his behaviors and attitudes impacted other people. To reduce guilt and minimize projection of blame and responsibility as well as Tomas's own anger and resentment for being criticized, Dr. Johns would normalize Tomas's behavior within the context of his narcissistic PD or the problems he was confronting in his life. Although not excusing or condoning the behavior, Dr. Johns's method neutralized the potentially overwhelming affect and made the underlying issues more approachable. Deep down, what Tomas feared the most was looking at the inner sense of emptiness that haunted him. Slowly, he came closer to getting in touch with those feelings. The mindfulness work was critical in that regard, because emptiness from a Buddhist perspective is not frightening; it is a crucial part of reality and, indeed, a necessary step in the path toward enlightenment. In sum, then, guided by Tomas's personality and his need for unconditional positive regard, therapy started by using a humanistic approach, using empathy and validation and examining the client's thwarted actualizing tendency. The emphasis then shifted to cognitive—behavioral interventions to challenge Tomas's beliefs about himself and others. As his self-image improved, he became better able to tolerate more intensive self-exploration. Sensitivity to issues related to sexual orientation, ethnicity, and religion were crucial to understanding Tomas's depression. The use of mindfulness meditation helped him tolerate his negative affect sufficiently to engage in the therapeutic process. The use of the empty chair technique then allowed him to increase self-awareness and more thoroughly integrate aspects of self that he had previously abhorred or tried to ignore or destroy. Thus, therapies were combined synergistically, with a trusting relationship forming the foundation on which challenge could be tolerated; mindfulness-based stress reduction enhanced Tomas's insight and distress tolerance, which allowed deeper explorations of his issues with his therapist. Psychodynamic theory was helpful in examining the transference—countertransference interactions and understanding his self-development of and the dynamics underlying his interpersonal relationships, as well as helping to integrate his internalized parental images and childhood experiences into his present reality. As a function of the positive relationship with the therapist, modeling, and active and persistent skill building, Tomas slowly became more empathic. At this writing, group therapy or couples work are possibilities for helping him to further reduce his narcissistic proclivities. Further goals of treatment include increasing his ability to self-validate and decreasing his addictive proclivities (e.g., to relationships, sex, drugs, and food), which he was using to fill the void he was experiencing, as well as ameliorating the subsequent excessive admiration seeking, multiple sex partners, procrastination regarding priorities like finding a meaningful job, and sidestepping his role as parent. NARCISSISTIC PERSONALITY DISORDER

207

SUMMARY AND CONCLUSIONS When treating individuals with narcissistic PD, maintaining rapport is often a substantial challenge. Blithely supporting the narcissist's grandiosity all but abandons any hope of therapeutic progress, whereas confrontation undertaken precipitously can undermine a fragile bond. Managing countertransference is often the most difficult problem the therapist faces. In my experience, concurrent mild to moderate depression generally facilitates motivation, thus adding to the probability of therapeutic success. All of these elements were demonstrated in the case of Tomas. Initially, the focus was validation in order to secure the relationship. As the therapy evolved, Dr. Johns managed his countertransference using mindfulness-based techniques; when he (Dr. Johns) was more centered, he was able to compassionately confront the client's grandiosity and lack of empathy. Tomas's depression and PD resolved in concert with one another. Depression in narcissistic PD requires a great deal of further research. Little is known about the biology of narcissistic PD, even though its heritability appears to be similar to that of other PD. Understanding the basic neurological mechanisms associated with the disorder may lead to improve' ments in both psychotherapy and medication management. Although I have argued that mild to moderate depression facilitates psychotherapeutic intervention with individuals with narcissistic PD, further research is needed to verify this hypothesis as well as to confirm other aspects of the relationship between depression and narcissistic PD.

208

PERSON ALITY-G UIDED THERAPY FOR DEPRESSION

10 DEPRESSION IN AVOIDANT PERSONALITY DISORDER

The phenomenon of avoidant personality disorder (PD) is brilliantly captured in Tennessee Williams's (1945/1999) The Glass Menagerie. The character Laura is so painfully shy that she is practically homebound; when she does go out, she does not interact with others. Desperately yearning for affection but believing that she is unlovable because of a disability, she interacts mostly with her somewhat overbearing and formerly very popular mother. Laura has relatively few lines, her attitude being conveyed largely by her fragile demeanor and wilting body language. A perceptive high school acquaintance, her date for the evening that her brother arranges for her (and apparently her first date ever) summarizes her difficulties: You know what I judge to be the trouble with you? Inferiority complex! ... A lack of confidence in yourself as a person. . . . For instance that clumping you thought was so awful in high school. You say that you even dreaded to walk into class. You see what you did? You dropped out of school, you gave up an education because of a clump, which as far as I know was practically non-existant [sic]! A little physical defect is what you have. Hardly noticeable, even! Magnified a thousand times by your imagination! (T. Williams, 1945/1999, pp. 80-81)

209

Laura is a tragic figure, because it seems clear as the drama unfolds that Laura could make a fine companion if only she could escape her demons.

PHENOMENOLOGY: THE EXPERIENCE OF AVOIDANT PERSONALITY DISORDER The individual with avoidant PD is characterized by a painful evasion of others for fear of rejection. Persons with avoidant PD play an emotional game of hide and seek, believing that as soon as their inner experience is known, they will be rejected because of their fundamental inadequacy. There is a profoundly hopeless feeling generated by such a belief. How can there be cause for optimism? To the extent that they are accepted, it is because they have managed to hide their real self from the other person; thus such acceptance cannot possibly feel safe, much less gratifying. In their minds, relationships hang by gossamer threads, waiting to be swept away. Often, the person prefers to strike preemptively, leaving a relationship before he or she can be rejected. Unlike the unemotional schizoid pattern, the avoidant pattern entails a yearning for relationships. People with avoidant PD suffer the torment of Tantalus, in which gratification is always in sight but just out of reach.

EPIDEMIOLOGY According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, 2000a), avoidant PD has a prevalence of 0.5% to 1.0% in the community. In outpatient clinics, the corresponding rate is approximately 10.0%. Avoidant PD is fairly prevalent in samples of depressed individuals. In a sample of 10Z individuals with recurrent depression, Pilkonis and Frank (1988) found that the prevalence of avoidant PD was 30.4%- Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 6.9% had avoidant PD. In Pepper et al.'s (1995) dysthymic disorder sample, 16% had avoidant PD. In Fava et al.'s (1995) sample of depressed clients, approximately 26% had avoidant PD. In a sample of 249 depressed outpatients, 13% were diagnosed with "definite" and 34% with "probable" avoidant PD (Shea, Glass, Pilkonis, Watkins, 6k Docherty, 1987). Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; 32% had avoidant PD. In a sample of 352 clients with both anxiety and depression, approximately 27% had avoidant PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, 6k Dunner, 1993). Thus, in the currently available studies on depressed samples, between 13% and 32% have comorbid avoidant PD. Likely reasons for the fairly wide range include natural sample

210

PERSON'ALITY-G UIDED THERAPY FOR DEPRESSION

variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria (e.g., some studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 1980], and some used criteria from the revised third edition [American Psychiatric Association, 1987]). Fewer data are available on the frequency of depression in avoidant PD samples, but the two extant studies are consistent with each other. A study of 157 clients with avoidant PD found that 81.5% had major depression (McGlashin et al., 2000). Zimmerman and Coryell (1989) studied a community sample of 797 individuals, which included 143 individuals who were diagnosed with PDs. Among those with avoidant PD, 80% met the criteria for major depression.

WHY DO PEOPLE WITH AVOIDANT PERSONALITY DISORDER GET DEPRESSED? Given their attitudes and beliefs, it is not surprising that people with avoidant PD get depressed; what is remarkable is that they have moments that are depression free. More than with most psychological conditions, persons with avoidant PD are trapped in a no-win situation. If they connect to others, they get rejected, whereas if they stay alone, they pine for a relationship. Weak and atrophied social skills make genuine connections difficult. Also, the belief that "to know me is to reject me" can serve as a nearly insurmountable barrier to interpersonal association, especially without treatment. In many cases, even relationships within the nuclear family are poor; as a result, the option of remaining comfortably connected to one's family of origin for positive social ties is often undesirable or even detrimental. Avoidant PD thus increases one's vulnerability to depression. In addition, depression and avoidant PD exacerbate one another; the depressed and avoidant person is all the more likely to withdraw, thus feeling even more depressed. It is also possible that depression, even after it remits, leaves the person vulnerable to increased avoidant behavior (e.g., in an effort to avoid the pain of rejection), which would be consistent with the "complications-scar" model (see chap. 2, this volume, for discussion of theoretical relationships between depression and Axis II disorders). One particularly painful period for a woman with avoidant PD is the point at which the ticking of the biological clock grows loud. In her 30s and realizing that she has never really dated effectively, the prospects of marrying and having children begin to fade. The thought of her loneliness continuing indefinitely without any hope of receiving the fantasized unconditional love from a child can be overwhelming.

AVOIDANT PERSONALITY DISORDER

2I1

HOW A PERSON BECOMES AND REMAINS AVOIDANT: THEORIES OF AVOIDANT PERSONALITY DISORDER Biological Factors Avoidant PD, conceptually, is almost synonymous with high levels of Cloninger's (1988) harm avoidance dimension. A series of studies of animals and humans have demonstrated the biological mechanisms underlying harm avoidance behavior. The evidence suggests that opposing processes in the serotonergic and dopaminergic systems originating in the brain stem and midbrain underlie avoidant behavior (Cloninger, 1998). Cloninger noted that individuals who are high in both novelty seeking and harm avoidance will experience approach-avoidance conflicts. According to Millon (1996), individuals with avoidant PD have an underlying desire to be accepted (unlike those with schizoid PD) and are thus prone to approach—avoidance conflicts. Behaviorally, however, they are consistently inhibited (unlike, e.g., the passive-aggressive/negativistic type). Heritability

Avoidant PD and related traits appear to be moderately heritable. A study by Livesley, Jang, and Vernon (1998), using the Dimensional Assessment of Personality Pathology, found that the Rejection Sensitivity scale had a heritability of 36%, and the Social Avoidance scale had a heritability of 38.4%. Coolidge, Thede, and Jang's (2001) study of children and adolescents found a heritability of 61% for avoidant PD. A meta-analysis by McCartney, Harris, and Bernieri (1990) showed a higher interclass correlation for monozygotic twins (.51) than for dizygotic twins (.19) on sociability, a dimension on which avoidant PD presumably represents the extreme low end. DiLalla, Carey, Gottesman, and Bouchard (1996) found that the Minnesota Multiphasic Personality Inventory Social Introversion scale has a heritability of 34%. Medications

Deltito and Stam (1989) discussed a series of four case studies of individuals with avoidant PD, most of whom had concurrent anxiety disorders on Axis I. Three responded well to a monoamine oxidase inhibitor (MAOI; tranylcypromine; phenelzine) and 1 to an SSRI (fluoxetine); these cases were reportedly representative of 20 similar patients whom the authors and their associates treated in their clinic. Their treatment was based on the notion that avoidant PD is similar to social phobia and would respond to similar medications. Although their study lacked rigorous methodology, their findings were generally encouraging. Ekselius and von Knorring (1998; see chap. 1 of this volume for a further description of the study) surveyed 106 individuals with avoidant PD at baseline. The SSRIs sertraline and citalopram ap212

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

peared to be helpful in decreasing avoidant PD symptoms. The remission rate for avoidant PD after 24 weeks of treatment was 27% for the sertraline group and 22% for the citalopram group; both reductions were statistically significant. Both the sertraline and the citalopram groups had a mean decrease of 0.6 criteria pre- to posttreatment, which was statistically significant. Unfortunately, because there was no medication-free comparison group, the results of the study are inconclusive; however, given the generally persistent nature of PDs, the finding is noteworthy and warrants further investigation. Seedat and Stein (2004) treated 28 individuals with generalized social anxiety, 23 of whom had avoidant PD. In a double-blind, placebo-controlled study, they tested whether adding clonazepam to a regimen of paroxetine was superior to paroxetine alone. Adding clonazepam did not produce statistically significant improvement, though the authors noted that the findings pointed in the right direction, and a larger sample may have yielded a significant improvement result. Reich, Noyes, and Yates (1989) conducted a study to examine the efficacy of alprazolam on avoidant personality traits in social phobia patients. For 9 of 14 patients, six of the measured avoidant traits improved with treatment; however, all traits, with the exception of avoiding social or occupational activities requiring interpersonal contact, returned to baseline levels after treatment was discontinued. Unlike the published research on medications for avoidant PD, the literature on medication for social anxiety and social phobia is substantial. Given the significant overlap in phenomenology between these disorders and avoidant PD (Rosenbaum & Pollock, 1994), it is worthwhile to consider the relevant studies. A literature review of over 20 placebo-controlled medication trials for social phobia (Davidson, 2003) reported that the MAOI phenelzine is effective in about 60% to 70% of cases and was superior to placebo in all of the studies reviewed; however, potentially dangerous side effects make it desirable to try other medications first. Reversible MAOIs such as moclobemide and brofaromine were considered "promising" but had less consistent findings than phenelzine and have limited availability in the United States. SSRIs were superior to placebo and were effective in about 43% to 70% of cases. Benzodiazapines were more effective than placebo, though they were generally considered a second-line treatment because of drug dependence, difficulties with withdrawal, and a limited spectrum of positive effects. Other medications, such as tricyclic antidepressants, buspirone, and beta blockers, were found to be either ineffective or of limited use. On the basis of the literature, Marshall and Schneier (1996) have constructed an algorithm for medication treatment of social phobia. They recommend starting with an SSRI; if there is no response, they suggest switching to clonazepam, but if there is a partial response, one can augment with a benzodiazapine or buspirone. If there is no response to clonazepam, they recommend using an MAOI, but if there is a partial response, they suggest adding an MAOI or buspirone. The prominent position of SSRIs is due to their AVOIDANT PERSONALITY DISORDER

213

excellent tolerability, safety, and positive outcomes in research. I must confess surprise at the recommendation to use buspirone at several points in the algorithm, given the weak research findings. Davidson (2003) noted that social phobia's approximately 35% to 65% response rate indicates that many patients do not respond to medications; even those who do generally have only a partial response. He recommended research on combinations of medications and on brain mechanisms that may provide keys to more effective treatments. To these excellent suggestions, I add that research on combined pharmacotherapy and psychotherapy would be in order. Finally, it is essential that more research be done on medication for avoidant PD itself; the studies with individuals with social phobia can only be considered useful beginnings toward finding medication treatments for avoidant PD. Psychological Factors Millon's Theory According to Millon (1969/1985, 1981, 1996, 1999), individuals with avoidant PD represent the "active-detached" type. They separate from others and do so in a purposeful and intentional way. Individuals with avoidant PD are thought to have an active, anxious, insecure nature, perhaps as a result of excessive neurological (limbic) substrates associated with painful emotion. These neural differences in adulthood may have been caused by genetics or shaped by experience. The early experiences of people with avoidant PD are likely to be characterized as anguished when hypersensitive children are routinely told they are no good. As Millon (1996) stated, Normal, attractive, and healthy infants may encounter parental devaluation, malignment, and rejection. Reared in a family setting in which they are belittled, abandoned, and censured, these youngsters will have their natural robustness and optimism crushed, and acquire in its stead attitudes of self-depreciation and feelings of social alienation, (p. 279)

Of course, the temperamentally irritable and hypersensitive child is more likely to elicit such rejection from well-meaning but ill-prepared parents and will be more easily devastated by their rejection. Difficulties in early parentchild interactions will predispose the child to further difficulties when he or she engages with peers. As rejection piles on rejection, the child internalizes a damaged and worthless self-image. Once the avoidant pattern is set in motion, various processes contribute to its self-perpetuation. The choice to withdraw from others socially means that individuals with antisocial PD are deprived of the opportunity to learn how to interact more effectively with others. Their fears of others and the suspicion that others will not only reject but also humiliate them naturally beget distrust. Their proclivity to scan the environment for threats, though 214

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

self-protective in intent, increases their encounters with hurtful stimuli; indeed, they may find rejection where most would not even notice a passing negative emotion. Another person's bad day is experienced personally as a barge full of rejection, even if it has little to do with the avoidant person's behaviors. The internal use of cognitive distraction also interferes with their ability to think clearly and thus engage in comfortable conversation, thereby deepening their already disturbing level of alienation. Thus the individual tends to remain isolated and fearful over time or, in many cases, becomes more avoidant and distressed over time. The description of the person with avoidant PD in terms of Millon's domains is presented in Appendix B. "Aversive interpersonal conduct" and "alienated self-image" are the most prominent features. Cognitive-Behavioral Conceptualization and Interventions Individuals with avoidant PD have a number of troubling cognitions that can lead to withdrawal and depression. Beliefs in their own worthlessness, inadequacy, and unlovability predominate. Intermediate beliefs such as, "If I interact with others, then I will humiliate myself; "Only by staying away from others can I remain safe"; and "If I can't be with others that accept me completely, then I am better off alone" undergird the avoidant pattern. Similarly, intermediate beliefs such as "If I get to know others, they will reject me"; "I'm so lonely I can't stand it"; and "Things will never get better, because I am too defective for anyone to like or love" steer the individual toward depression. These underlying beliefs, which emerge after a period of exploration, underlie the automatic thoughts that occur spontaneously and are readily seen in therapy. Typical automatic thoughts for the person with avoidant PD include "If I talk to her, she won't like me"; "If I speak up in class, I will make a fool of myself; and "I give up—I can't go on this way." Viewed in this light, the enormous covariation between avoidant PD and depression becomes sensible: The same core beliefs often underlie both. A. T. Beck and Freeman (1990) observed that a personal history of rejection, particularly by close significant others, provides a powerful learning history that establishes the avoidant pattern. Parental rejection is, understandably, particularly hard on a child. They noted, Avoidant patients must make certain assumptions to explain the negative interactions: "I must be a bad person for my mother to treat me so badly," "I must be different or defective—that's why I have no friends," "If my parents don't like me, how could anyone?" (p. 261)

Through the error of overgeneralization, children then learn to withdraw socially, fearing rejection. They interpret rejection from others as proof of their differentness, unlovability, and inadequacy. Believing the negative messages, they become highly self-critical. They may describe themselves as AVOIDANT PERSONALITY DISORDER

215

boring, stupid, and unattractive. As a function of these self-critical proclivities, individuals with avoidant PD are particularly sensitive to thoughts about depression that enhance and deepen their negative mood. They are likely to have thoughts such as "It is terrible to feel badly as I do" and "Other people rarely feel depressed or embarrassed." Avoidant PD is somewhat similar to paranoid PD in that forming a therapeutic relationship generates considerable anxiety on the part of the person with this disorder, and early in treatment, there is a substantial risk of premature termination. Clients may flee after admitting to a flaw, believing that the therapist now knows how defective they are and will therefore reject them for therapy. It is important to screen for these thoughts by asking openended questions about the thoughts and feelings of the client, such as "How did it feel when you told me that?" and "What thoughts are going through your head?" Once the relationship is formed, it tends to be very strong, because, as previously noted, attaining an accepting relationship is extremely rewarding for the person with avoidant PD. Standard cognitive and behavioral techniques are generally effective. Skill building is often essential. It has been my experience that a person with avoidant PD often does relatively well within the safe confines of the therapeutic relationship but is extremely awkward in day-to-day social situations. Large quantities of role-play and practice are often helpful. A. T. Beck, Freeman, and Davis (2004) further recommended role play with rejecting and critical others from the past, which often results in substantial reconceptualizations of the client's history. They gave the following example: Mother:

Jane: Mother: Jane: Mother:

Jane: Mother:

216

[played by the therapist] You're no good! I wish you were never born! The only reason your father left us was that he didn't want you. Don't say that, Mommy. Why are you so angry? I'm angry because you're such a bad child. What did I do that was so bad? Everything. You're a burden. You're too much to take care of. Your father didn't want you around. I'm sad Daddy left. Are you sad, too? Yes. Yes, I am. I don't know how we're going to get by.

Jane:

I wish you didn't get so mad at me. I'm only a kid. I wish you would get mad at Daddy, instead. He's the one who left. I'm the one who's staying with you.

Mother:

I know. I know. It wasn't really your fault. Daddy isn't living up to his responsibilities.

PERSONALITY-G U1DED THERAPY FOR DEPRESSION

Jane: I'm really sorry, Mommy. I wish you didn't feel so bad. Then maybe you wouldn't yell at me so much. Mother:

I guess I do yell at you because I'm unhappy, (pp. 313-314)

By seeing her mother simultaneously through her adult eyes and the eyes of a 6-year-old child, Jane came to understand a new interpretation—that her mother's problems caused much of the shaming and that Jane herself was just a typical child. It was no longer automatic for Jane to assume that she was bad and wrong. The therapy continued with considerable work challenging Jane's belief that she was unlikable and building a new schema, namely, that she was likable to at least some people. In addition to role-play, Socratic dialogue helps to challenge clients' negative beliefs about themselves. Thought records, similarly, reinforce the habit of challenging negative thoughts and replacing distorted beliefs with more realistic ones. As the underlying core beliefs of inadequacy, worthlessness, and unlovability are assuaged, both the avoidant PD and the depression resolve. Psychodynamic Therapy The withdrawal from social life by the person with avoidant PD is, in broad terms, an effort to manage anxiety. The origins of this anxiety vary from case to case. However, in many cases, it appears to be rooted in shame. Unlike guilt, which is experienced by the individual when wishes or actions conflict with the constrictions imposed by the superego, shame is experienced when the individual fails to live up to the ego ideal. In general, individuals with avoidant PD use repression and other high-level defenses and do not show identity diffusion;1 thus they can be seen as being organized at the neurotic, as opposed to borderline or psychotic, level of personality functioning. As such, the individual with avoidant PD would be expected to form a relationship with the therapist somewhat more easily than the borderline, paranoid, or schizoid client, a prediction that fits well with clinical experience. Gabbard (1994) recommended warm and empathic support coupled with firmly suggesting to clients that they expose themselves to feared social situation to become more aware of the specific fantasies that they have. These fantasies often lead to associations with childhood experiences that have important etiological significance. He gave a case example of a 24-year-old woman who had intense fears in social situations. Because she was very pretty, she got asked out often but relied on alcohol to soothe her anxieties sufficiently for her to cope and to help her to open up. During one session, when

'Identity diffusion indicates a changeable and unstable sense of self, often manifested by frequent changes in appearance, social group, and vocational and avocational activities.

AVOIDANT PERSONALITY DISORDER

217

she was particularly quiet, he asked her if she was concerned about how he would respond if she were to share her thoughts and feelings. She replied that she was extremely afraid of losing control of her emotions, anticipating that the therapist would shame her and accuse her of being like a baby. This brought back memories of her harsh and critical father, who not only shamed her for having emotions but also for receiving positive recognition of any kind (accusing her of being a "show-off"). Thus, the client not only feared criticism but also was frightened by her (normal) exhibitionistic desires and her need for affirmation. As she worked through her difficulties with these issues, she found that she was able to go out and enjoy herself without becoming inebriated. COUNTERTRANSFERENCE When individuals with avoidant PD enact their avoidance within the therapy—for example, by canceling appointments or avoiding anxietyprovoking material, therapists often feel frustrated. Typical thoughts about the avoidant patient may include the following: "The patient isn't trying." "She won't let me help her." "If I try really hard, she'll drop out of therapy anyway." "Our lack of progress reflects poorly on me." "Another therapist would do better." The therapist thinking these types of thoughts may begin to feel helpless, unable to assist the patient in effecting significant change. (A. T. Beck et al., 2004, p. 316)

Challenging such thoughts, of course, would be critical to the success of the therapy. Research on graduate students' and clinicians' responses to filmed vignettes of individuals with avoidant PD supports and extends the patterns observed by A. T. Beck et al. (2004). Participants initially responded to individuals with avoidant PD by feeling perplexed, disconnected, and frustrated, which appear to be responses to the cognitive avoidance of the client and to his or her reticence in trying new strategies to connect with others. In addition, participants reported feelings of pity and feeling responsible for the person. The individual's apparent fragility seemed to pull strongly for such feelings. Many participants felt sad, downhearted, or melancholy, which was a straight empathic response to the depression and sadness evident in the individuals portrayed in the vignettes used in the study (Bockian, 2002a; see chap. 1, this volume, for further description of this study). Like the participants in the study, the emotion with which I must frequently grapple when dealing with individuals with avoidant PD is pity. The clients are generally terribly sad and distressed, they feel completely hopeless, and they effectively convey that hopelessness to the therapist. Nonetheless, pity is not only a nontherapeutic stance but also an iatrogenic one. When I feel it, I vigorously search for its origins and actively reframe it. The 218

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

pull for pity is highly informative; it suggests that others in the client's environment feel the same way and often that individuals with avoidant PD feel sorry for themselves. Such hypotheses can be easily checked. For example, at some point, when someone treats these clients well, they will likely hypothesize that the other person was nice "because she felt sorry for me." The role of pity in the client's life can then be discussed openly. Once I find the origins of my feelings of pity—usually an understandable reaction to the person describing a highly pained existence—I can challenge the thoughts with Socratic questioning. "Is the situation really hopeless? Is it possible that by changing her behaviors she can elicit different responses? Does she have any strengths that would be appealing to anyone? Can at least some of her avoidant behaviors be turned around? Don't Vicious circles' tend to work in reverse, in that, just as failure breeds failure, success breeds success?" Now, with a more neutral stance, I am able to help the person consider some additional possibilities. The most frustrating part of the disorder is the cognitive avoidance. The individual is sincere and motivated but cannot endure the pain of selfexploration long enough to get anything done. In such circumstances, I remember Marsha Linehan's (1993) simile regarding persons with borderline PD—they are like burn patients and have no "emotional skin." Imagine being so hypersensitive that to talk about one's deficits that may need correction is like a torrent of humiliating criticism. Imagine having a background in which your internalized significant others are "vexatious" internalized tormentors waiting to be unleashed by the slightest provocation. If this is true for the person who has avoidant PD, it is all the more true for the individual who concurrently has comorbid depression. When I empathize with the person more intensely, I am better able to be patient and to recognize that we may need to take very small steps. The average person with a PD needs at least a year or two of treatment, and maybe this person needs more. So, each session, if we make a fraction of a percent of the total improvement we are hoping to attain, we are doing fine. As I discuss in the chapter on antisocial PD (chap. 6, this volume), it is often important for therapists to check on their own motivations for wanting a patient to make progress at a certain rate; if the client can wait, then so can I. Breathe in, breathe out.

SOCIAL CONSIDERATIONS AND DIVERSITY Avoidant PD may be viewed as a sign of a "stigmatized moral career" (see chap. 3, this volume). Individuals who are lower on the social hierarchy may feel inadequate and handle those feelings through social avoidance. Thus, avoidant PD is more likely to occur in hierarchical societies such as the United States. In some individuals from non-Western societies, however, the behavior may have a very different meaning. For example, people from India, AVOIDANT PERSONALITY DISORDER

219

especially young women, are taught to behave deferentially. Such individuals should not be diagnosed with avoidant PD (Castillo, 1997) for this reason alone. DSM-IV-TR noted that difficulties with acculturation following immigration may falsely appear to be avoidant PD. STRENGTHS OF PERSONS WITH AVOIDANT PERSONALITY DISORDER Individuals with avoidant PD or features are often attracted to, or adept at, poetry or other artistic endeavors. Their hypersensitivity often shades into finely attuned and acute attention to subtle nuances of feeling. Such individuals may do well with journaling or expressive arts therapy. Avoidant behavior is a part of everyone's experience. Who among us has not stopped to "lick their wounds" after a painful breakup and avoided dating or other forms of social contact for a period of time? Though this pattern goes too far in avoidant PD, when used appropriately, avoidance is part of the repertoire of useful coping patterns. TREATMENT PLANNING: SYNERGISTIC TREATMENT Personality-guided therapy treatment goals flow logically from the conceptualization of the client, per Millon's (1996, 1999) theory. The person with avoidant PD is considered the active-detached type, so naturally the goal is to balance the polarities by helping the client to become less active and more attached to others. Because the person is hypersensitive to pain, an additional goal is to decrease pain and increase pleasure. It is also important to undermine processes that tend to perpetuate the avoidant pattern. As noted above, vicious circles of persons with avoidant PD include social detachment, suspicious and fearful behavior, hypersensitivity to rejection, and cognitive self-distraction. Therefore, therapy should be geared to reduce their fears, attune their internal cognitions, and increase social activity (see Exhibit 10.1). The long-term goals for depressed individuals with avoidant PD include increasing their activity level, enhancing pleasure, improving their social interactions and increasing their frequency, and bringing focus to their distracted cognitions to help them recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma & Peterson, 1999). Individuals with avoidant PD have substantial difficulties with trust. Establishing a trusting relationship is no small task, although in general, prospects for success are good if the therapist is patient and supportive and if the therapist takes the important step of checking in frequently with the client to make sure that there are no cognitive distortions that could interfere with the therapeutic relationship. Judith S. Beck (1995) recommended a review 220

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

EXHIBIT 10.1 Therapeutic Strategies and Tactics for the Prototypical Avoidant Personality STRATEGIC GOALS Balance Polarities Diminish anticipation of pain Increase pleasure/enhancing polarity Counter Perpetuations Reverse social detachment Diminish suspicious/fearful behavior Moderate perceptual hypersensitivity Undo intentional cognitive interference TACTICAL MODALITIES Adjust alienated self-image Correct aversive interpersonal conduct Remove vexatious objects Note. From Personality-Guided Therapy (p. 319), byT. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

at the end of the session asking if the client has any questions or needs any clarifications. Specifically asking during the session, "Did anything bother you?" has a good chance of eliciting distorted thoughts that the therapist was judging the client harshly. Whenever making any suggestions for a change in behavior, the therapist should be aware that the client could interpret what was said as form of rejection. One technique that can be helpful in such circumstances is to make a "compliment sandwich" when providing feedback to the avoidant client. The therapist can compliment the client, then provide criticism or suggestions, then compliment again. For example, one could say, You did a great job paying attention to your feelings while you were so uncomfortable meeting with your boss. I wonder if you would like to try some assertiveness techniques. I think you have the ability to do it, if you feel ready.

When this suggestion is framed in the context of his or her strengths, even the person with avoidant PD would be unlikely to feel rejected. Conversely, a more unfettered and, ordinarily, effective statement such as "You seemed to feel uncomfortable; perhaps some assertiveness techniques would help," could trigger a surprising cascade of thoughts, such as the following: I knew I should have stood up for myself. Now he thinks I'm weak. He probably doesn't even want to do therapy with someone as weak as me. I'm too much work for any therapist. It's hopeless. I shouldn't come back next week. He'll be happier with me off his caseload. AVOIDANT PERSONALITY DISORDER

221

Clients with both depression and avoidant PD are at particularly high risk for such distortions. Regardless of therapist orientation, the initial relationship with the person with avoidant PD should resemble Rogers's (1979) approach: warmth, empathy, and unconditional positive regard. Persistent support early in therapy generally secures the therapeutic relationship, which, once established, tends to be very solid; having an accepting other in their lives is generally greatly needed and appreciated by individuals with avoidant PD. Once the relationship is established, a variety of approaches can be used either separately and sequentially or in a more parallel and simultaneous fashion. Typically, clients can explore the roots of their difficulties while also participating in cognitive exercises to challenge some of their cognitive distortions and behavioral techniques to become engaged with other people. Group therapy can be particularly helpful for individuals with avoidant PD, particularly if the group is free from hostile and attacking members and instead is composed of others who are supportive and interested in being supported. The group can provide a safe intermediate environment between the therapy environment and the "real world," a place where the client can ask for feedback from others, who are unlikely to be as harsh as his or her own inner critic. In cases where the family is unwittingly promoting the avoidant pattern, family therapy may be useful to help clients to gain more intimacy in their marriage or other close relationships and to help family members to better understand the client's worldview. Improvements in any area—cognitive, behavioral, or interpersonal— are likely to lead to a positive cascade of improvements that are isomorphic to but move in the opposite direction from the "vicious circle." For example, changes in the client's belief from "I am defective" to "I am a person who has some flaws and some strengths" changes the likelihood that the client will risk having a relationship with another person. If the relationship goes well, that is likely to lead to a reduction in depression, a further willingness to risk being in a relationship, and a further change in beliefs (e.g., reduced beliefs of defectiveness, increased beliefs of being worthwhile).

CASE EXAMPLE: JORDAN Jordan was 20 years old when he was seen by Michelle Rodgers in a college counseling center for depression, which was impacting his academic work. He was born in Korea, and his family immigrated to the United States when Jordan was approximately 7 years old. His parents made a middle-class living as shopkeepers. Jordan was very hesitant to come to therapy, believing that it was a sign of weakness. When he started therapy, Jordan had lost his appetite, had great difficulty sleeping, and had significant suicidal ideation. Because of the severity of his depressive symptoms, Dr. Rodgers considered a

222

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

referral to psychiatry for a medication evaluation, but Jordan was adamantly opposed. Jordan had numerous thoughts that were consistent with his depression, colored by the context of his avoidant PD. Tall, athletic, and handsome, Jordan had never dated despite a strong desire to do so. His automatic thoughts were, "If I ask her out she'll reject me," and "If people get to know me, they won't like me." The underlying core beliefs were feelings of worthlessness and unlovability. Although he was a bright student on academic scholarship at a top university, he still felt stupid and useless. He engaged in a great deal of dichotomous thinking and was prone to making overgeneralizations. For example, because he was rejected by some people, he believed he would be rejected by all people, and if he was not acceptable to everyone, then he was worthless. Dr. Rodgers initiated cognitive therapy, both on the general principles of personality-guided therapy and also because cognitive-behavioral therapy tends to be more acceptable to Asians than insight-oriented approaches (Paniagua, 1994). Dr. Rodgers initially used mood logs and thought records to help Jordan build a mood vocabulary and to track variations in mood that would stand as evidence against his belief that he felt miserable all the time. Jordan had an extremely limited emotional vocabulary, what Levant (1995, 1998) would have called "normative male alexithymia." This was shaped in part by his gender and in part: by his culture; in Korean culture, it is more acceptable to describe somatic experiences rather than emotional ones (Paniagua, 1994). In the United States, we might call this somatization, but, from an Asian perspective, Westerners inappropriately "psychologize" what are really somatic concerns (Domino & Lin, 1991). However, given that Jordan's goal was to adjust to mainstream culture on a U.S. university campus, some emotion-focused work was highly appropriate. Simultaneously, Dr. Rodgers was aware that acculturation, intergenerational distress associated with differential acculturation levels of the client relative to his parents, and internalized racism appeared to be major issues for this young man, and they would be addressed later in the therapy. In addition to mood logs, thought records, and corresponding Socratic dialogue, Dr. Rodgers assigned books on self-esteem and assertiveness as bibliotherapy. Jordan read the books with great interest. Role-play helped him to implement the relevant behaviors. He first tried some assertiveness with his friends (e.g., asserting where he wanted to go out rather than just going along with the group). Rather than the expected rejection, his friends expressed pleasure in knowing where he stood. This experience was one of several crucial turning points for Jordan, who started to dismantle his automatic thoughts about others. He also began to recognize that he in fact did have some friends, counter to his notion that he was completely isolated and, thereby, completely unlovable.

AVOIDANT PERSONALITY DISORDER

223

Having made some significant gains, the therapy became increasingly focused on where Jordan's behaviors originated and how his beliefs developed and unfolded. Jordan's experiential history fit well with what would be expected on the basis of his current beliefs and avoidant functioning. His father had a problem with alcohol and was routinely abusive, critical, and demeaning toward Jordan. Although Asians use a more stern disciplinary style than Americans and are more prone to use physical discipline (Forehand & Kotchick, 1996), the father's drunken rages were abusive even within that context. Both parents worked almost constantly; thus there was little emotional support available from either. Although his father stopped drinking after being diagnosed with a heart condition and his behavior changed dramatically for the better, a great deal of damage had already been done. Incidentally, because of his experiences with his father's drinking, Jordan chose to be abstinent. Jordan's transference evolved over the course of treatment. Initially, he saw Dr. Rodgers as an authority figure and deferentially tried to please her. A mirroring transference then developed, which allowed Jordan to receive muchneeded validation that he had never attained as a child. He then began to idealize Dr. Rodgers, at which time he began to take psychology courses, considered changing his major to psychology, and considered becoming a therapist. Later in the therapy, he seemed to relate to her as he did to his older sister. Although his sister took care of him, she also had a tendency to direct his life, engendering feelings of affection but also resentment on Jordan's part. When the client began to work on issues involving dating, the transference became somewhat erotically tinged, although never to a degree that it became a significant source of resistance, and these feelings resolved on their own without the need for confrontation. In general, Dr. Rodgers experienced Jordan as likable, because he was very kindhearted, but often experienced frustration with him. Her countertransference also entailed the belief that the client was fragile, which she challenged internally and found was not true. The principal areas of frustration involved Jordan's cognitive avoidance, which was manifest in his failure to do homework and his proclivity to be stubborn. On one occasion Dr. Rodgers shared her frustration with Jordan. He became enraged—his hands were trembling, his face was flushed, and he could barely get his words out. Dr. Rodgers worked through the feelings by listening, and by validating how it was natural to feel angry given his perspective. She then confronted some of the distortions in Jordan's beliefs that gave rise to his anger. This intervention helped to model a path through which Jordan could resolve his own emotional difficulties. The honest expression of feelings did not impair the relationship or entail rejection; rather, it strengthened the relationship and expressed trust. This intervention paved the way for confrontations with his sister, which also went well. Jordan then realized that he needed to confront

224

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

his father. He had deep-seated feelings of rage about the abuse he had suffered at his father's hands and feelings of resentment about how his dad was still controlling his life (e.g., by pressuring him to choose a particular major). First, Jordan wrote a letter to his father, which was processed with Dr. Rodgers and never sent. He then confronted his father verbally over the issue of his current need for independence. His father was warm and supportive, stating that he "only wanted him [Jordan] to be happy." This shocked Jordan. Though happy that his father was supportive, he was confused, because it shattered his all-bad image of his father, and he would thus need to reintegrate a new image. Throughout the therapy, Jordan had largely avoided the topic of how being Korean influenced him. He had pretty much all White friends and never got involved in any of the Asian activities on campus. However, as his self-image improved, he became more interested in his Asian heritage and what that meant to him. Dr. Rodgers disclosed to him that she was half Japanese, which greatly facilitated his opening up and exploring these topics. Jordan made a great deal of progress working through his internalized racism. Toward the end of therapy, in what was a huge step for him, Jordan did ask a girl on a date—arid got rejected. However, he was able to frame the asking itself as a success. He asked a second girl out on a date and this time was accepted. He began to date occasionally, and one of the girls he asked out was Asian. At the end of the spring term, as is common in college counseling centers, it was time to terminate. Because Dr. Rodgers would not be returning the next year, the therapy could not continue in the same manner in the fall. With his improved self-image and social skills, Jordan was ready for group therapy, and collaboratively, they decided that Jordan would join a therapy group at the counseling center. In addition to being an opportunity to learn more about how others perceived him, the group was led by an Asian therapist who could potentially act as a role model. In sum, the therapy consisted of initial cognitive-behavioral interventions, which provided relatively rapid reduction of depressive symptoms. The therapy was also informed by self psychology and psychodynamic theory, particularly in the analysis of the transference and the countertransference as they coevolved in treatment. Jordan's improvements prepared him for a wider range of treatment options, particularly group therapy, and if he was interested, in psychodynamic therapy. Sensitivity to cultural diversity issues facilitated further self-image improvements. Jordan's depression was completely remitted at the end of this 9-month, 25-session treatment, and his avoidant PD symptoms were dramatically reduced. Further therapy would have been useful in continuing to resolve his relationship difficulties with his father, looking at his issues with his mother, and continuing to strengthen his self-confidence and social skills.

AVOIDANT PERSONALITY DISORDER

225

SUMMARY AND CONCLUSIONS Individuals with avoidant PD, if the therapist attends appropriately to the client's hypersensitivities, usually can form an appropriate therapeutic bond; in that regard, prognosis is more hopeful than with some other PDs (e.g., paranoid). My clinical experience corresponds to the available epidemiological data, which suggest that nearly all individuals with avoidant PD present with depression (80% had major depression; presumably, at least some if not most of the remaining 20% had minor depression, dysthymic disorder, or adjustment disorder with depressed mood). Thus when I treat someone with avoidant PD, depression is a routine consideration. Treating depressed individuals with avoidant PD first involves establishing rapport, which can be tricky, especially if the client evidences cognitive avoidance. As illustrated in the case example, forming a true therapeutic alliance can emerge deep into the treatment, when there is sufficient trust for the client to challenge his beliefs about the therapist's opinion of him. As in the case study, cultural considerations often play a crucial role in the therapist's understanding of the client and thus in his or her ability to become and to stay connected. Dr. Rodgers's understanding of her own emotional response to Jordan, and her ability to process this crucial information with him, also led to a turning point in the case. Thus, although the interventions were primarily cognitive-behavioral, psychodynamic, self psychology, and interpersonal considerations were keys to bringing the case to a successful conclusion. There are many areas to research in the treatment of comorbid avoidant PD and depression. Biologically, there may be causal links between the two disorders, which warrant exploration. For example, there may be biological factors unique to the avoidant-depressed combination, which, if discovered, would lead to more effective medication regimens. Psychologically, it would be helpful to find out, using prospective studies, what psychological factors lead to avoidant PD. Although current models emphasize rejecting and critical parenting; as illustrated by the case example, it could be that there are distortions in recall (e.g., the person with avoidant PD may misjudge his or her parents retrospectively). Such studies may also uncover a subset of individuals with avoidant PD who lack depressive symptoms, allowing comparisons between the depressed and nondepressed groups; given that nearly all individuals with avoidant PD present to clinics with depression, such comparisons are currently impractical.

226

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

11 DEPRESSION IN DEPENDENT PERSONALITY DISORDER

The phenomenon of dependent personality disorder (PD) was eloquently described by Paul Mason and Randy Kreger (1998): Imagine the terror that you would feel if you were a 7-year-old, lost and alone in the middle of Times Square in New York City. Your mom was there a second ago, holding your hand. Suddenly the crowd swept her away and you can't see her anymore. You look around frantically, trying to find her. Menacing strangers glare back at you . . . This is how people with [borderline PD] feel nearly all the time. (p. 27)

Substitute "dependent PD" for "borderline PD," and the description fits almost perfectly; the difference is that people with dependent PD do not project hostile intentions onto others. The underlying fear of death if not protected by a powerful other, however, is shared. Phenomenologically, individuals with dependent PD are passive and clingy. Generally, the conscious and ostensible reason for their dependent behaviors is poor self-esteem and low self-confidence. Their motto is, "I can't possibly do it; if I try do to it I'll only mess it up. Could you do it for me? Please?" The hope is that someone will take care of them and nurture them. In return, they offer unparalleled loyalty. In its milder form, it is not alto227

gether a bad arrangement for the partner, and some individuals with dependent features settle comfortably into a stable subordinate relationship with another individual. The "ideal" marriage of the not-so-distant past, with the working husband and the adoring wife, had some of these qualities. The division of power was never quite as neat as it appeared on the surface, however, and the feminist movement of the 1960s changed that prototypical relationship pattern. However, dependent PD goes much further. The incompetence becomes more global. The strain on the partner to make more and more decisions, so that even the most minor decisions require his or her input, takes its toll. The "supermom" prototype is the woman who works, takes care of the children, and cleans the house; the mom with dependent PD would be one who struggles in all of those domains. Even if she has no job outside the house, she feels unable to take care of the children (because she is unable to assert adequate authority) and in fact demonstrates incompetence in childrearing and even in housekeeping ("It's so hard"). Constant demands for reassurance add to the strain on the partner. Understandably, many partners bum out, bringing about the most feared consequence of all: abandonment. For men with dependent PD, or even features of it, the disorder seems to be even more disruptive. In Western culture, there really is little place for a dependent male. For the most part, men are uncomfortable taking subordinate roles and are expected to be wage earners. I am reminded of the case of a Hispanic couple in which the man had dependent PD. He achieved pseudoindependence by starting his own business, but unable to set limits with his employees, he was never able to earn much money. Warm and nurturing, he would have been a very good stay-at-home dad, though he would have needed to learn a bit more about boundaries with the children. Mom had no such difficulty; her character was a combination of obsessive-compulsive, histrionic, and aggressive features. A hardheaded business manager, she was working her way up the ladder in a medium-sized corporation. Given their culturally defined gender roles, the couple could not simply fall into a comfortable pattern. Both struggled mightily to fit into a pattern that was against both of their natures: He had to be the "strong one" and the wage earner; she had to be the subordinate wife. In recent generations among Americanized couples, however, more flexible gender roles are possible. It is becoming more common for the wife to work and the husband to stay at home; this becomes particularly likely when the woman is the better educated or higher earning of the two.

EPIDEMIOLOGY According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000a), dependent PD is among the most prevalent of the PDs in mental health clinics. 228

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

According to a quantitative review by Mattia and Zimmerman (2001), dependent PD has a prevalence of approximately 2.2% in community samples. In a sample of 102 individuals with recurrent depression, Pilkonis and Frank (1988) found that the prevalence of dependent PD was 15.7%. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 3.4% had dependent PD. In Pepper et al.'s (1995) dysthymic disorder sample, 9% had dependent PD. Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; 21% had dependent PD. In Fava and associates' sample of depressed clients, approximately 12% had dependent PD (Fava et al., 1995). In a sample of 249 depressed outpatients, 6% were diagnosed with "definite" and 20% with "probable" dependent PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). Finally, in a sample of 352 clients with both anxiety and depression, approximately 8% had dependent PD as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Thus, in currently available studies of depressed samples, approximately 3% to 21% have dependent PD. Viewed from the opposite direction—starting with individuals with dependent PD—fewer data are available. Zimmerman and Coryell (1989) studied a community sample of 797 individuals, which included 143 individuals who were diagnosed with PDs. Among individuals with dependent PD, 28.6% met the criteria for major depression. A meta-analytic review of 18 studies indicates that women are 40% more likely to be diagnosed with dependent PD than men (cited in Bornstein, 2005). This careful, well-reasoned review considered four possible causes of the gender gap. The first is sampling bias, which refers to the collection of nonrepresentative samples; if the prevalence of dependent PD is high in females in some samples but not others and the former group of samples are disproportionately represented in population estimates, then a gender difference would be reported erroneously. Because the gender difference is robust across settings, however, it is unlikely that nonrepresentative sampling could have caused the observed difference. The second possibility is diagnostic bias, which refers to a clinician's misdiagnosis based on his or her preconceptions. Bornstein (2005) ruled out this possibility as well. Three available studies, one of which had a sample of over 1,000 psychiatrists, psychologists, and social workers, presented written simulated cases that differed only by gender. In all of the studies, women were not more likely to be diagnosed with dependent PD; indeed, in one of the studies the male participants were diagnosed as having dependent PD in 52% of the cases, as opposed to 39% in the female cases, and in the other two studies the diagnostic rate was about the same. The third model, criterion sex bias, would be applicable if the criteria themselves were inappropriately sex linked; an extreme example would be criteria linked to the menstrual cycle or other female-only characteristics. It is difficult to get empirical evidence on the topic because more subtle forms of criterion sex bias will always be in the eyes of the beholder. On the basis of DEPENDENT PERSONALITY DISORDER

229

Reich's (1990a, 1990b) work, Bornstein reasoned that if the diagnostic criteria are biased, then one would expect to find that the men diagnosed with the disorder would be more pathological and probably would have different demographics; if men and women diagnosed with dependent PD have similar demographics and overall levels of pathology, then the criteria are probably performing appropriately. Several studies have shown that men and women diagnosed with dependent PD have similar demographics and overall levels of psychopathology; thus the sex-biased criteria model seems unlikely. Finally, there is the self-report bias model, which is the theory that men and women vary substantially in their willingness to acknowledge or disclose dependency-related behaviors and attitudes. A substantial body of evidence indicates that gender differences emerge more strongly as the face validity of the measure increases (cited in Bornstein, 2005). Bornstein conducted a largescale meta-analysis of sex differences in dependency (cited in Bornstein, 2005), analyzing 97 studies. Results indicated clearly that on self-report tests, such as the Millon Clinical Multiaxial Inventory—III (MCMI-III; Millon, 1994) and the Minnesota Multiphasic Personality Inventory, there was a positive correlation between femininity and dependency and a negative correlation between masculinity and dependency; although Millon did not report a combined effect size, it appeared to be moderate in magnitude.1 The opposite was true, however, for projective measures; men scored higher on projective dependency scales than did women.2 Concluded Bornstein, "It may be that men and women have comparable underlying dependency needs, but women are more willing than men to acknowledge these needs when asked" (2005, p. 11). Overall, then, Bornstein (2005) logically concluded that there is gender difference in diagnosis of dependent PD and that it is due at least in part to differences in self-report tendencies between men and women. He recommended using multiple assessment techniques (e.g., self-report plus projective tests) to minimize this bias. Other hypothesized sources of bias seem unlikely.

WHY DO PEOPLE WITH DEPENDENT PERSONALITY DISORDER GET DEPRESSED? The primary distinguishing reasons for depression among individuals with dependent PD are fear of abandonment and actual abandonment. To 'Bornstcin (2005) reported 10 effect sizes; the median value was approximately d = .44- Cohen's d is the number of standard deviations of difference between the groups. Therefore, on self-report tests, women scored higher than men by about four tenths of a standard deviation, which is considered a medium magnitude. : Bornstein (2005) reported that the effect size was small (d = .11) but statistically significant; on projective tests dependency scores for men were higher than those for women by about one tenth of a standard deviation.

230

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

empathize with the dependent client, it is necessary to imagine, as noted in the beginning of this chapter, the intensity of the belief that one's very life depends on the beneficence of others. Often, such beliefs are subconscious or preconscious, although in at least some cases clients have full awareness of their fears. The passage from Mason and Kreger (1998), quoted above, about the terror of a lost child may be a metaphor, but I have seen cases in which the intensity of such a belief is manifest. I once treated a person with a bluecollar job who was being hit by her husband. She would not leave him on the basis of the following argument: "My husband hits me, but if I left him, I could only afford to live in a neighborhood that is so dangerous that I would probably be killed." It is possible that she was correct, but I believe it is more likely that her beliefs were distorted and betrayed an underlying dependency; she earned more money than others I knew who managed to live in reasonably safe conditions. The relationship between dependent PD and depression, given the conceptualization above, becomes apparent; the belief that one is helpless has long been known to underlie feelings of depression (Seligman 1975). In addition, object loss often leads to depression, particularly in a predisposed individual (Blatt, 1974; Blatt, Shahar, & Zurhoff, 2002; Freud, 1917/1986). As demonstrated in empirical research (see the section on epidemiology, above) depression frequently overlaps with dependent PD. Thus dependent PD creates a vulnerability to depression. In addition, depression and dependent PD likely exacerbate one another; for example, the person with dependent PD generally clings so hard that rejection becomes likely, thus increasing rejection and dependency needs synergistically (see chap. 2, this volume, for further discussion of the relationship between depression and Axis II disorders).

HOW A PERSON BECOMES AND REMAINS DEPENDENT: THEORIES OF DEPENDENT PERSONALITY DISORDER Biological Factors According to Cloninger's (1987) model, individuals with dependent PD would be low on novelty seeking, high on harm avoidance, and high on reward dependence. This theory suggests several patterns that are important in the development and maintenance of dependent PD. Dopamine depletion is related to low novelty seeking; for example, individuals at risk for Parkinson's disease have low levels of novelty seeking (Cloninger, 1998). High harm avoidance is related to higher levels of activity in the right amygdala, the right orbitofrontal cortex, and the left medial prefrontal cortex. High reward dependence is related to elevated activity in the thalamus, which is consistent with the theory that serotonergic projections from the DEPENDENT PERSONALITY DISORDER

231

thalamus to the median raphe nuclei play an important role in the reward dependence dimension. Thus one would expect to see these biological patterns in the individual with dependent PD. Heritability

Limited available evidence suggests that dependent PD is moderately heritable, at a level similar to other personality disorders. A study by Coolidge, Thede, and Jang (2001) found that dependent PD had a heritability of .61 in a sample of children and adolescents. Livesley et al. (1998), using the Dimensional Assessment of Personality Pathology, found a heritability of 33.6% on the submissiveness scale and 43.6% heritability for insecure attachment. Medications

An uncontrolled trial by Ekselius and von Knorring (1998) has suggested that the SSRIs sertraline and citalopram were associated with statistically significant decreases in dependent PD diagnosis rates and symptoms among the 61 individuals with dependent PD in their sample (see chap. 1, this volume, for a further description of the study). The remission rate for dependent PD after 24 weeks of treatment was 61% for the sertraline group and 57% for the citalopram group. The sertraline group had a mean decrease of 0.9 criterion pre- to posttreatment; the corresponding figure for the citalopram group was 1.0 criterion. Unfortunately, because there was no medication-free comparison group, the results of the study are inconclusive; however, given the long-standing nature of personality disorders, the finding is promising and warrants further investigation. A study by D. W. Black, Monahan, Wesner, Gabel, and Bowers (1996) was less encouraging, indicating a lack of response by participants with dependent PD symptoms to fluoxetine. Other than that, there appear to be no studies of medications used with dependent PD. Given the paucity of available data, it is worth considering the suggestions by Joseph (1997) based on his clinical experience. Joseph noted that the clinging behavior of the person with dependent PD may include aspects of anxiety (e.g., fear of abandonment) and depression (e.g., difficulty coping with loss). Thus, he asserted that individuals with dependent PD often respond to medications that are helpful with anxiety and depression. In his recommendations, Joseph (1997) noted, The first-line medications for depression and anxiety in modern psychiatric practice are the serotonergic antidepressants, venlafaxine, mirtazapine, and nefazodone because of their favorable side effect profiles and their effectiveness in the treatment of anxiety. However, all antidepressants including MAOIs, trazodone, [tricyclic antidepressants] and bupropion, should be effective. In addition to antidepressant treatment, patients with Dependent Personality Disorder may benefit from 232

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

adjunctive treatment using antianxiety medications, either on a standing basis, or preferably, on a [given as needed] schedule, (p. 1^0)

Joseph further noted that many people with dependent PD present with dysthymia or dysthymic symptoms and thus may benefit from long-term pharmacotherapy. There is an obvious need for studies that investigate whether dependent symptoms can be alleviated with medications. Given its nascent stage of development, our understanding of the biology of dependent PD could be greatly facilitated by basic science, presumably related to biological studies of attachment in general. In addition, given the high prevalence of depressive disorders and dependent PD and their moderate overlap, there is a great need for studies that assess the effectiveness of pharmacotherapy in individuals with both disorders. Ultimately, randomized clinical trials are necessary to establish the efficacy of various medications for symptoms of dependent PD. Psychological Factors Milloris Theory According to Millon's (1996) tridimensional system, dependent PD represents the passive-dependent adaptation. Unlike the active-dependent (histrionic) types, who use their charm or appearance to get their needs met, the passive-dependent individual waits and hopes, dreaming that a rescuer will magically appear. The presumed developmental history of the person who develops dependent PD is that of a temperamentally placid, passive child. Although many individuals who develop psychopathology have histories of neglect, the opposite is generally true of budding dependents. Significant others such as parents rush in to fill the void left by the person's natural passivity. Potential incompetence becomes actualized as opportunities to grow and learn from mistakes are turned away. Reduced competence leads to further overprotection and further incompetence. Although burdened with feelings of helplessness and skill deficits, this kind of experiential history tends to imbue the individual with an unshakable sense of optimism, a belief that others tend to be good and helpful rather than undermining and malevolent, and basic trust in others. Even among those who are depressed and thus currently pessimistic, this underlying optimism is generally a resource waiting to be tapped. Millon's (1996) domain descriptions are provided in Appendix B. Of the domains, submissive interpersonal conduct and inept self-image are the most salient. Cognitive-Behavioral Conceptualization and Interventions From a cognitive perspective, individuals with dependent PD have a number of beliefs that tend to interfere with their functioning. Ideas such as DEPENDENT PERSONALITY DISORDER

233

"I need help making a decision" and "I can't stand being alone" shape much of the individual's adaptation to the world. Helplessness schemas (Young, 1999) are often triggered by depression in the individual with dependent PD. Dichotomous and global styles of thinking, such as believing "I am incompetent," can be challenged with great effectiveness using Socratic dialogue (e.g., "Are you incompetent at everything? Is there anything at all that you do adequately, or even partly adequately?"). Under such questioning, it is rare that even an extremely dependent and moderately depressed person cannot find an area of partial competence. Depressions that are so severe that one cannot even imagine anything positive about oneself may benefit from early psychopharmacological interventions to facilitate availability to the therapeutic process; in contrast to many clients with PDs, premature termination is rarely a cause for concern in the person with dependent PD. A. T. Beck and Freeman (1990) astutely noted that [dependent PD] can be conceptualized as stemming from two key assumptions. First, these individuals see themselves as inadequate and helpless, and therefore unable to cope with the world on their own . . . Second, they conclude that the solution to the dilemma of being inadequate in a frightening world is to try to find someone who seems to be able to handle life and who will protect and take care of them. (p. 290)

In other words, the individual with dependent PD has the core beliefs "I am helpless" and "I am inadequate" and the intermediate beliefs "Only if I can find someone to take care of me will I be okay," and "If I can't find someone to take care of me, it's awful." Directly confronting and dispelling negative core beliefs can have far-reaching consequences for a wide array of behaviors and attitudes. If the client no longer believes that he or she is helpless, which acts as a pillar supporting an entire building of beliefs, then hundreds of specific automatic thoughts can be rapidly changed. In the case of dependent PD, skill building can in fact challenge the core belief directly. Significant changes, especially in the client's depression, can occur after only a dozen or so sessions (see the case example at the end of this chapter). As with all PDs, however, treatment can easily take a year or two before the PD can be considered adequately treated. A variety of behavioral techniques can be very helpful to the person with dependent PD. For example, dependent PD can be seen as an extreme form of underassertion; thus, assertiveness training can be beneficial. The therapist should not assume that problem-solving and decision-making skills have been learned but are being ignored for emotional reasons; in fact, it is likely that the client has not mastered these important skills and would benefit greatly from learning them. Client-Centered, Humanistic, and Existential Therapies

Client-centered therapy provides a nurturing environment for the person with dependent PD. By its firm, nondirective stance, client-centered 234

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

therapy implicitly forces the client to make decisions and differentiate in a healthy way. Though making decisions and differentiating may be uncomfortable for the client at times, the supportive stance of the therapist and the proclivity of the dependent client to form strong attachments and thus stay in therapy bode well for the ultimate success of treatment. Psychodynamic Therapy

Freud (1940/1969) discussed the oral phase as a normal part of development. In addition to nourishment, the infant derives sensual gratification while nursing. Throughout the first 18 months of life, the developing child focuses a great deal of libidinal energy on the oral area, putting objects in the mouth, sucking the thumb and pacifiers, and so on. When the child is frustrated during the oral phase, there is a negative kind of orality, associated with sarcasm and feelings of pessimism. Overindulgence, on the other hand, leads to much more positive feelings. Abraham (1911/1986) discussed how overindulgence during the oral phase of development leads to the formation of a dependent character. In a later work, Abraham (1924/1983) stated, According to my experience we are here concerned with persons in whom the sucking was undisturbed and highly pleasurable. They have brought with them from this happy period a deeply rooted conviction that everything will always be well with them. They face life with an imperturbable optimism which often does in fact help them to achieve their aims. But we also meet with less favourable types of development. Some people are dominated by the belief that there will always be some kind person—a representative of the mother, of course—to care for them and give them everything they need. This optimistic belief condemns them to inactivity, (p. 131)

Gabbard (1994), however, noted that this narrow view of the relationship between early life events and later character pathology is no longer widely held in psychodynamic circles. He suggested it is more essential that a pattern of dependency be fostered throughout all phases of development, and that parents consistently communicate that independence is dangerous. To my knowledge, psychodynamic theorizing regarding dependent PD has been modest. I assume that this is because dependency issues respond well to traditional psychodynamic and psychoanalytic techniques. Although splitting defenses and borderline pathology, for example, presented the therapeutic community with a tremendous challenge, dependency issues are considered a routine part of much psychodynamic treatment; dependency during psychoanalysis does not necessarily imply dependent psychopathology, because it is a phase of treatment that is relatively common among many analysands. More extreme dependency, then, does not necessarily demand a different approach to treatment. Thus, although dependent PD is relatively common, it has generated less research and scholarly interest than, for example, borderline and narcissistic PDs. DEPENDENT PERSONALITY DISORDER

235

Family Systems

Often, individuals with dependent PD are attracted to people with narcissistic PD as partners. In many ways, it is a perfect fit. The individual with narcissistic PD (usually a male) needs to be admired, likes to feel like the strong one, and has fantasies of unlimited success; the person with dependent PD (usually a female), low in self-esteem, tends to fawn, wants someone strong to take care of her, and tends to gullibly believe what others tell her. Couples in which one person has a mildly dependent style and the other a mildly narcissistic style often do very well. When each person is at the PD level, however, the relationship typically becomes problematic. Often, the narcissistic husband becomes derogatory toward his wife, believing that she is "beneath" him. The very subservience he craves makes her appear inadequate and useless. He may get involved in an affair with someone "more worthy"—prettier, more accomplished, or higher in social status. Even in the absence of an affair, his lack of empathy can, over time, be emotionally devastating for his wife. Dependent pathology, likewise, can create enormous marital strain. The low self-esteem and instrumental incompetence of the wife can be draining to even the most selfless husband, much less to one with narcissistic pathology; no matter how much he nurtures, her craving for care will make his efforts seem inadequate.3 Placing another person into the position of always having to be the strong one and falling apart if he ever shows neediness can be difficult for anyone; for someone with narcissistic problems, the pattern may be a painful reenactment of childhood experiences. Nurse (1998) recommended a structured treatment based on Millon's (1996) theory. Clients present for treatment, often with one of the issues enumerated above. The MCMI-III is administered to each client. In addition to work on the couples issues that have brought them to treatment, the uniqueness of each individual is emphasized, on the basis of the assessment. The second session is then an individual one, which is used to provide feedback from the MCMI—III assessment. When the couple comes back together for the next session, they are asked to share what they learned about themselves. With the dependent-narcissistic couple, two of Millon's (1996) polarities are particularly out of balance: the self (individuation)-other (nurturance) dimension and the passive (accommodation)-active (modification) dimension. On the former, the narcissistic member of the dyad is too self-focused, whereas the dependent member is too other-focused. Thus the therapist needs to encourage the dependent client to individuate and to become more assertive and more self-reflective. The narcissistic client, conversely, benefits from empathy training and encouragement to focus on the other person's needs. 'Individuals with dependent PD usually have a degree of actual incompetence, the result of a history of overprotection and reliance on others, which then tends to be exaggerated in their own minds as extreme incompetence and helplessness.

236

PERSONAllTY-G VIDEO THERAPY FOR DEPRESSION

On the latter dimension, both are too passive and need to be moved to a place of increased activity.

COUNTERTRANSFERENCE As in the case of histrionic and borderline PDs, individuals with dependent PD can elicit rescuer fantasies and behavior. Noted A. T. Beck, Freeman, and Davis (2004), The temptation to rescue the [dependent PD] patient is particularly strong, and it can be very easy either to accept the patient's belief in his or her own helplessness or try to rescue the patient out of frustration with slow progress. Unfortunately, attempts at rescuing the patienr are incompatible with the goal of increasing the patient's autonomy and selfsufficiency, (p. 279)

The manner in which the person with dependent PD calls for rescuing is somewhat different from that of clients with other PDs. In borderline PD, the client often threatens or engages in self-destructive behavior (especially suicidal gestures and attempts), which elicits rescuing responses. Persons with histrionic PD have a flighty, scattered presentation that leads the therapist to believe that they are unable to think through problems for themselves; additionally, their dramatic, seductive behavior impels the therapist to play the hero. Persons with dependent PD present themselves as incompetent and pathetic, which prompts the therapist to want to solve their problems for them (A. T. Beck et al., 2004). The therapist ultimately can become frustrated with the client's passivity and dependency (Bornstein, 2005) and may entertain thoughts that the client truly is incompetent or even stupid or that the client is feigning incompetence for effect (A. T. Beck et al., 2004). Therapists may experience pleasurable feelings of power in response to the patient's submissiveness (Bornstein, 2005). Of course, such beliefs and feelings must be examined. Research on graduate students has shown that they typically feel sad, pitying, and depressed in response to a film of someone simulating dependent PD. Participants have noted that they believed the client's life was very restricted and seemed unfulfilling, which accounted for much of their sadness and pity. They typically also have an urge to rescue the client, which is consistent with the sad, pitying reaction. Participants also felt curious, and they found themselves leaning forward with interest. One of the films drew a frustrated, angry, irritated response. In that particular film, the client was involved in what appeared to be an abusive relationship but would not talk to the therapist unless the presumed perpetrator was in the room. This atypical scenario, in which the dependent transference on the therapist was blocked by an obsessive attachment to a significant other, left the therapists in trainDEPENDENT PERSONAL/TV DISORDER

237

ing feeling unable to be helpful and thus frustrated; they were irritated with the client for not taking better care of herself and angry at the presumably abusive boyfriend (Bockian, 2002a; see chap. 1, this volume, for a further description of this study). For better or for worse, and probably like many other clinicians, I respond positively to clients whose dependency needs drive them to be cooperative and eager to see me. I often feel a powerful urge to rescue them—I call that "being on my horse," the image of the knight in shining armor racing off to protectively slay the dragon for another person. I want to take away their pain, right away. Once I experience such feelings, I typically look for related thoughts and challenge them using cognitive techniques: Is she really so fragile? Can she tolerate some discomfort in order to achieve her long-term goals? Do others respond in the same way? How would I feel if everyone around me viewed me as being in need of rescuing? Would I wear out my welcome? By exploring my thoughts in this way, I usually can "get off the horse"—that is, get away from the rescuing stance and come to a more balanced assessment of the person. After this preliminary positive reaction, with clients whose dependency issues are more severe and persistent I often feel burdened and drained. Some clients, unintentionally and unconsciously, have a vampiric quality, draining my energy to support themselves. In such cases, I often experience discomfort and a desire to get away. Once again, using self-awareness and cognitive strategies, I pay attention to what 1 am feeling and imagine what it would be like to be that person. Desperate for support, they probably experience persistent rejection; after all, if I, in my role as a paid, professional support person, feel drained, imagine how the person who is a "volunteer" must feel! Feeling more compassionate, I am then able to explore my hunches and usually do find that the person does indeed persistently feel rejected and alone. I have, however, observed a strongly different reaction in a number of my students. Among those who have somewhat obsessive-compulsive personality styles and have strong values that a person must be "productive," individuals with dependency issues arouse strong judgmental thoughts. Students who are highly independent often find the dependent client annoying and pitiful. I encourage them to explore their reactions in light of their personal and cultural values.

SOCIAL CONSIDERATIONS AND DIVERSITY In many subcultures, polite and deferential behavior is considered appropriate. Many cultures, especially those of Asia, are sociocentric. Independent decision making is less common than in highly autonomous Western 238

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

cultures. Castillo (1997) gave the example of Japanese society; in that culture, children are taught "the nail that stands out gets hammered down" (p. 107). In many such cultures, unlike the United States, adolescents are not expected to make important life decisions (e.g., which college to attend). Such behaviors and attitudes should not be considered features of dependent PD, particularly if they are not problematic in the person's subculture. As noted above, more females acknowledge dependency and are diagnosed with dependent PD than males. Willingness to acknowledge dependency is likely impacted by cultural factors, such as differential acceptability of expressing reliance on another for men and women. Communitarian cultures tend to tolerate dependent behavior more than independent cultures; for example, Bornstein and Languirand (cited in Bornstein, 2005) found that adolescents and young adults in India and Japan demonstrated higher levels of self-reported dependency than similar populations in North America. They concluded, "Studies indicate that gender role norms can have a powerful impact on women's and men's willingness to acknowledge underlying dependency needs" (Bornstein, 2005, p. 8).

STRENGTHS OF THE PERSON WITH DEPENDENT PERSONALITY DISORDER Individuals with mild dependent PD symptoms manifest a variety of strengths. As noted previously, such individuals tend to be optimistic. They are trusting and trustworthy and thus tend to engender trusting relationships. They tend to be kindhearted, and when the disorder is not severe they tend to give in addition to receiving help. Individuals with dependent PD features are very well suited to situations in which it is appropriate to receive help passively (such as receiving some types of medical care) or to seek it actively (such as attending a professor's office hours). As mentioned previously, individuals with dependent PD tend to be extremely loyal, which facilitates reciprocal loyalty and closeness with others. Institutional living, though less than ideal, may be required in cases of severe physical or mental disability; in such cases, being passive and submissive, unfortunately, tends to be highly adaptive. Bornstein (2005), on the basis of numerous studies, described strengths in individuals with healthy dependency. Individuals with healthy dependency are sensitive to social cues, including verbal and nonverbal communication. They have high levels of insight and integrate therapist feedback into their self-concept, leading to positive change. The friendships of individuals with healthy dependency are characterized by openness and flexibility, and their romantic relationships are marked by mature intimacy and open communication. At work, they are congenial, cooperative, and focused on the needs of the group. Finally, as parents, they use an authoritative style and set limits in an appropriate, flexible manner. DEPENDENT PERSONALITY DISORDER

239

TREATMENT PLANNING: SYNERGISTIC TREATMENT Unlike the situation with many of the other PDs, developing a therapeutic bond with individuals with dependent PD requires relatively little special effort. Unless the therapist actively pushes the person away (e.g., because of discomfort with dependency or premature efforts to force independence on the client), then the client will naturally bond with the therapist, falling into a help-seeking role. A. T. Beck et al. (2004) pointed out that allowing such dependency to form is not problematic early in treatment as long as it is clear that the long-term goal is for the client to be able to help him- or herself. Cognitive and behavioral interventions can be used simultaneously to challenge the client's view of him- or herself as incompetent. Through skills training and use of thought records and Socratic dialogue, individuals with dependent PD will tend to become more competent and to recognize their abilities. The process of increasing independence can occur within the therapy; while initially providing structure, the therapist can require increasing input from the client in setting agendas and determining therapeutic activities. Interpersonal conceptualizations are almost always necessary or implied with the person with dependent PD because they define themselves in relation to others rather than as independent beings. Clientcentered therapy, with its firm nondirective stance, would also require that the client structure the session and thus become more independent. Once the client has gained some improved competence, group therapy interventions can further reduce the dependence on the therapist and provide an opportunity to try new behaviors (e.g., assertiveness) in a relatively safe environment. Because the client is unlikely to flee from therapy, psychopharmacologic interventions can be implemented early to help reduce depressive affect. Psychodynamic interventions can also help to deepen the client's selfunderstanding and understanding of the impact of early childhood events— especially helpful is the confrontation of the dependent transference. The key to successful treatment, regardless of the theory used in understanding the person or the particular intervention used, is maintaining a warm but firm stance that the client find a way to be competent and to feel successful. It is important to note that a wise and realistic overall goal of treatment is to bring the person with dependent PD to a state of healthy dependency, rather than autonomy. Noted Bornstein (2005), When working with a dependent patient—especially one who is extremely clinging and insecure—it is easy to overemphasize autonomy at the expense of healthy dependency. Although increasing autonomous functioning is an important goal of clinical work with dependent patients, autonomy is most adaptive when it is expressed in flexible, situationappropriate ways and combined with a willingness to seek help and support from other people, (p. 147)

240

PERSONALITY-G UIDED THERAPY FOR DEPRESSION

EXHIBIT 11.1 Therapeutic Strategies and Tactics for the Prototypal Dependent Personality STRATEGIC GOALS Balance Polarities Stimulate active/modifying polarity Encourage self-focus Counter Perpetuations Reduce self-depreciation Encourage adult skills Diminish clinging behaviors TACTICAL MODALITIES Correct submissive interpersonal conduct Enhance inept self-image Acquire competence behaviors Note. From Personality-Guided Therapy (p. 377), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

As seen in the section of this chapter on the strengths of dependent PD, there is a positive place for individuals with healthy dependent traits. Guidelines for conceptualizing and implementing the personality-guided paradigm are provided in Exhibit 11.1.

CASE EXAMPLE: ELISA When I started seeing Elisa, she was a 68-year-old widow who was living in a nursing home. She was a Caucasian Protestant of mixed northern European descent. At that time, Elisa had mixed features of anxiety and depression. She had a history of being diagnosed with both schizophrenia and bipolar disorder for many years. She took lithium and a small amount of a low-dose neuroleptic, and she was stable on her medications. From time to time I reported side effect problems (e.g., a tremor in the hand) to her psychiatrist, but in general she tolerated the medications well. Although 1 saw some evidence of mood swings, I never observed any overt schizophrenic symptoms. The initial phase of treatment was intended to establish rapport, which occurred readily using active listening and reflecting and other techniques that originated in the client-centered tradition. I have found rapport building to be unusually easy in nursing homes. Despite the image of older adults as therapy avoidant, seeing therapy as being something for "crazy people" and as a severe encroachment on their independence, there is a factor at

DEPENDENT PERSONALITY DISORDER

241

nursing homes that overrides all other considerations: loneliness. Most residents in nursing homes spend a good deal of time alone or, if with others, sitting in front of a television set together. Certainly, the nursing home made substantial efforts, providing trips to local restaurants, bringing in entertain' ment frequently, and so on. Nonetheless, mobility impairments and cognitive impairments limited certain kinds of activities, and many residents had difficulty energizing themselves to participate in activities. Loneliness is so pervasive in nursing homes that the opportunity to spend a chunk of time with a cognitively intact person who will provide one with warm, supportive contact is very appealing. Because of the relatively sparse activities between sessions, transference tends to be intensified. In contrast to the situation of clients in typical outpatient settings, family contact does not occur daily. The sheer quantity of time spent with the therapist, at 50 to 100 or so minutes per week, rivals the amount of time spent with family (which occurs for longer periods of time but less frequently). Contact with other nursing home residents occurs frequently, but in many cases such others are activity partners, and the relationships often lack substantial depth or intimacy. These factors were generally true in Elisa's case, as elaborated below. Elisa was the youngest of three siblings. Her oldest brother, Martin, was married and had two children. The middle brother, Erik, never married. Elisa had been married to Jack for approximately 3 years. They had a daughter, Caroline, about 2 years into the marriage. Elisa described the marriage as being a very good one. Unfortunately, when Caroline was just a year old, Jack died of a heart attack. Erik moved in and helped to raise Caroline. Elisa never remarried, and she and Erik continued to live together for many years. However, Erik's health had recently begun to fail. He was spending more time in the hospital than out and was no longer able to help Elisa in her dayto-day activities. Thus, Elisa had moved into the nursing home. In terms of countertransference, I generally liked Elisa. I found myself feeling the typical emotions I feel with many people with dependent PD: nurturing, rescuing, and concerned. This "rescuer" reaction is a reliable sign for me that the individual has dependency issues and helps to clarify several aspects of the client's situation. In this case, one was that she presented herself as being fragile, as if her pain would break her. A moment's reflection revealed that in fact this was a woman who had coped with a great deal of pain in her life, including several psychiatric hospitalizations as well as the death of her husband and both parents. She had had copious family support throughout her life, which was extremely helpful to her in surviving these difficulties. Reflecting on these facts and being aware that my role was to help her balance the dependence-independence (other-self) polarity, which was currently excessively tilted toward dependence, helped me to "get off the horse"—that is, regain my footing and help her to become more independent rather than simply helping her transfer her dependency from someone else onto me. 242

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

I also more than occasionally felt bored during our sessions and had thoughts about how we would fill the 50 minutes we had together. These are generally reliable signs for me that the person has schizoid features. The blandness, lack of emotional intensity, and lack of drama tend to leave me feeling a bit bored; relative to what one might expect from someone who fits the "pure" dependent prototype, Elisa's emotional reactions were muted, and she was more self'focused. With some clients with schizoid PD, there are difficulties in finding clear, collaboratively developed goals, which can create a sense of futility for both therapist and client; this was not a problem in Elisa's treatment. The feeling of struggling to keep the conversation going, however, speaks to the client's overall passivity and to my own distaste for long periods of silence during therapy sessions. It cannot be ruled out—in fact, I believe it is most likely—that medications strongly contributed to Elisa's emotional flatness or bluntness. Thus she may not have been schizoid in Millon's (1996) sense, in which there is an underlying defect in emotional processing. Rather, medications, especially lithium and low-dose neuroleptics, may have made her appear relatively flat or, over time, may have induced a degree of blandness that would not otherwise have been present. It is also important to note that Elisa felt best when with others and uncomfortable when alone, which, in and of itself, virtually rules out schizoid PD proper. Given the mix of features, Elisa would best fit Millon's "ineffectual" subtype of dependent PD. Elisa was referred to me because she was feeling "nervous" and "down." She had a number of specific concerns. Her main concern was for her brother Erik, on whom she relied and who was extremely ill. Elisa specifically requested hypnosis because a friend of hers had had hypnosis with good effect. The use of hypnosis with people with psychotic disorders can be tricky, and one must use good judgment and appropriate precautions. Because she had asked for hypnosis, turning her down because of her history would inevitably carry a meta-message that she was too sick and too damaged to receive the treatment she saw as best, perhaps even magical. I checked with staff and with her records and saw that she had been stable on medications for a long time, at least a year with no psychotic episodes. Because I generally work with light trance and had rarely encountered any untoward effects, I decided to work with her hypnotically. The hypnosis that I used with Elisa was similar to that used by Yapko (2001) in the treatment of depression. It was primarily cognitive-behavioral in its theoretical underpinnings. I would induce a state of trance using standard techniques. I would then have her imagine situations in which she would become anxious or depressed, and we would then "build in" coping strategies. I would suggest that when she felt bad (either "nervous" or "down") a variety of coping strategies would "automatically" come to mind. These coping strategies had been collaboratively constructed prior to the session. They included going for a walk, talking to a friend, calling a family member, and so DEPENDENT PERSONALITY DISORDER

243

on. Elisa reported a powerful relaxation response during the session; I also observed rapid eye movements, suggesting that she achieved good depth of trance. The intervention was highly effective, and her use of various coping strategies increased dramatically. Encouraged by Elisa's success with this relatively structured intervention, I implemented a permissive imagery intervention, which allowed her to go to a special place that she found comforting. This, too, was successful, helping to reduce Elisa's anxiety without provoking any abreactions, regressions, psychotic phenomena, or other problems. Elisa's free-floating anxiety—her vague nervousness for which she had no awareness of an immediate cause—abated within a few sessions. That in and of itself was a substantial improvement in her emotional condition. However, her reality-based fears regarding her brother's health, her fears about her ability to survive if he died, and her underlying depression regarding the loss she was potentially facing were issues that required further intervention. In addition to the hypnosis, which we continued as part of the therapy for much of the treatment, Elisa and I began to do a good deal of cognitive restructuring. I helped her to challenge her beliefs regarding the thoughts that left her feeling depressed and anxious. At times, Elisa engaged in all-ornone thinking. For example, after her brother moved out of the house, she was fearful that her possessions would be discarded by the realtors or that the house would be sold and she would not have an opportunity to retrieve her possessions. She was overwhelmed by feelings of helplessness and spent a great deal of time worrying and ruminating. Using cognitive techniques, we were able to assess the likelihood of her fears coming true. We examined the evidence—statements from her brother, from the real estate agents, and so on. We assessed whether these people were trustworthy on the basis of her experience. Once she was reassured that the items were not likely to be discarded, we were able to explore the meanings she attributed to her possessions. Some of them, such as her wedding album, had a great deal of emotional significance, as an attachment to her long-lost husband. Other items, such as some articles of clothing, lacked sentimental significance and were left at home because she did not have room in the nursing home. Although the sale of the house itself was an obvious symbol of a decision to permanently reside in a nursing home, the attachment to the clothing, in part, represented the assumption that someday she would return home. It is probably hard for most middle-class individuals to accept that all of their worldly possessions would fit in the small closet and few drawers available in a semiprivate nursing home room, and that was true for Elisa. However, it was also true that she lived simply and was able to work through the loss of the home. It helped greatly that Elisa truly enjoyed living in the nursing home. The relationships suited her, and the nurses who helped her monitor her medications were a source of security and comfort. If her brother were not with her, she in fact would be lonely living at home. 244

PERSONAL/TY-GU/DED THERAPY FOR DEPRESS/ON

After about 15 to 20 sessions, Elisa would have been ready for a tapering of sessions. However, at about that time, there was a crisis. Her brother's health took a severe turn for the worse. I spoke with Erik, who had been transferred to the same nursing home as Elisa. He was in bad shape medically—he was emaciated, pale, and weak. He was also severely depressed. I made an appointment to see him to treat his depression, but I never got to keep it. Within a week, he had been transferred to a hospital, where he expired. Elisa was, of course, devastated. She cried frequently throughout the day. Her face was drawn, and she had a pained expression constantly. Although this was an expected grief reaction, given the closeness of the relationship, I was a bit concerned because, given her bipolar disorder, it was not clear how Elisa would respond biochemically. Because Elisa was not only grieving for a loved one but experiencing the loss as a threat to her existence and her way of life, I conceptualized her reaction as grief but likely to be complicated by depression. We increased session frequency to twice per week. With increased support, she did relatively well. Within a few weeks, the deepest grief had lifted. She had transferred much of her dependency needs to the nursing home. Reassured that she would be okay, she was able to experience the loss of Erik as a deeply saddening event but not a threatening one. After approximately 1 year of treatment, we were able to comfortably terminate by reducing session frequency. Elisa was moving to a new nursing home to be near her daughter's family.

SUMMARY AND CONCLUSIONS The principles of personality-guided therapy indicate a catalytic sequence that simultaneously addresses depression and the relevant PD. The illustrative case in this chapter drew on synergistic combinations of a variety of treatments. Client-centered techniques were used to establish a connection. Once the alliance was formed, cognitive-behavioral techniques helped the client to improve her skills and her self-image. Hypnosis in this case had a somewhat paradoxical flavor; although the client was passive during the hypnosis sessions, virtually all of the suggestions were designed to help her increase her activity level, coping, and competence. As she became more competent and less needy, her interpersonal relationships improved. Ultimately, her depression lifted, she became more able to enjoy her time with her family, and they were better able to enjoy their time with her. There are many areas that require further research in examining the relationship between dependency and depression. Biological information, including basic neurological mechanisms underlying the disorders as well as the effectiveness of medications, require further elaboration. Prospective studies assessing how dependent PD develops, and cross-sectional studies to asDEPENDENT PERSONALITY DISORDER

245

sess the relationship between childhood precursors of dependent PD and associated theory-derived risk factors (e.g., perceived incompetence and overprotective parenting style) would be an invaluable contribution. In the context of these improved understandings, theory regarding the interaction between and concomitant development of depression and dependent PD would be more meaningful.

246

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

12 DEPRESSION IN OBSESSIVECOMPULSIVE PERSONALITY DISORDER

The phenomenon of obsessive-compulsive personality is whimsically illustrated in the Disney children's movie Mary Poppins (Stevenson, 1964/ 2004) in the character of Mr. Banks. Preoccupied with order and productivity, he is ruining his relationship with his children. The song "A British Bank" summarizes his philosophy: A British bank is run with precision A British home requires nothing less! Tradition, discipline, and rules must be the tools Without them—disorder! Chaos! Moral disintegration! In short, we have a ghastly mess!1

The song goes on to describe, with blithe indifference to reality, how the children (approximately 9 and 6 years old) should get excited about see'From "A British Bank (The Life I Lead)" from Walt Disney's Mary Poppins. Words and music by Richard M. Sherman and Robert B. Sherman. Copyright 1963 by Wonderland Music Company, Inc. Copyright renewed. All rights reserved. Used by permission.

247

ing profits rise on a ledger sheet and implies that any activities just for fun are a waste of time. Mr. Banks's discussions with the happy-go-lucky chimney sweep, Bert, prompt him to question his choices; when Mr. Banks loses his job (at the bank) he reconsiders his values and begins spending joyful leisure time with his family. Despite the film's focus on magical Mary, it is actually Mr. Banks who undergoes the most dramatic transformation and learns to balance his life in a satisfying way.

PHENOMENOLOGY: THE EXPERIENCE OF OBSESSIVE-COMPULSIVE PERSONALITY DISORDER According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, 2000a), The essential feature of Obsessive-Compulsive Personality Disorder is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, (p. 725) Individuals with obsessive—compulsive personality disorder (PD) are noted for their rigidity, orderliness, attention to rules, and attention to details. They generally deny emotional experience, perhaps not wanting to appear weak to others but, more likely, pushing the emotional experience out of their own awareness. Unlike the schizoid client, who appears to be largely unable to experience emotions, persons with obsessive-compulsive PD appear to be channeling emotions or shutting them down. Perhaps as a consequence of their inability or unwillingness to experience or deal with their emotions, they tend to be more vulnerable to somatization disorder (e.g., hypochondriasis; Garyfallos et al, 1999), which thus allows individuals to express a variety of emotions under the safe rubric of medical illness. Illness can allow them to be nurtured by others without asking for nurturance or can excuse them from work when their "internalized taskmaster" would never allow them an idle moment. Neil Simon's play The Odd Couple (1966), which also was made into a movie and a long-running TV series, turned Felix Unger, a highly prototypical, tragicomic person with obsessive-compulsive PD, into something of a cultural icon. Felix had essentially every symptom of the disorder—excessive neatness and orderliness, excessive attention to detail, high and rigid moral standards, and even somatization in the form of allergies. Despite the similarity in names, there is no clear relationship between Axis I obsessive-compulsive disorder (OCD), and Axis II obsessivecompulsive PD. Hoarding, and perhaps miserly spending, are shared by the two disorders. Empirically, findings have been mixed as to whether there is a relationship or not (Spitzer 6k Dieter, 1997). Millon (1999) argued that the 248

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

names of the disorders should be different to avoid misleading users of DSMIV-TR into thinking there is a relationship between the disorders. In this chapter, I differentiate between them by using the two separate terms indicated earlier in this paragraph.

EPIDEMIOLOGY According to DSM-IV-TR, obsessive-compulsive PD has a prevalence of approximately 1% in the general population and 3% to 10% in mental health clinics; it occurs approximately twice as often in males as in females. An excess of occurrence in males was also found in a sample of individuals who had both obsessive-compulsive PD and depression (Carter, Joyce, Mulder, Sullivan, & Luty, 1999). Mattia and Zimmerman's (2001) quantitative literature review showed that among the six studies that attempted to measure the prevalence of obsessive—compulsive PD in the community, the median prevalence was 4.3%; these studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) and the revised third edition (DSM-III-R; American Psychiatric Association, 1987). In a sample of 102 individuals with recurrent depression, Pilkonis and Frank (1988) found that the prevalence of obsessive-compulsive PD was 18.6%. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), 4.3% had obsessive-compulsive PD. In Pepper et al.'s (1995) dysthymic disorder sample, 4% had obsessive-compulsive PD. In another sample of depressed clients, approximately 30% had obsessivecompulsive PD (Fava et al., 1995). In a sample of 249 depressed outpatients, 13% were diagnosed with "definite" and 39% with "probable" obsessivecompulsive PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). In a sample of 352 clients with both anxiety and depression, approximately 20% had obsessive-compulsive PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). A study of 622 participants with anxiety disorders found that 15.4% of individuals with major depression (and, by definition, at least one anxiety disorder) had obsessivecompulsive PD, which was the second most frequent Axis II condition among those with depression (Dyck et al., 2001). The range, then, is approximately 4% to 20%, or as many as 39% if one includes those classified as "probable." Likely reasons for the wide range include natural sample variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria (e.g., some studies used DSMIII criteria and some used DSM-III-R criteria); further studies of the prevalence of obsessive-compulsive PD in depressed samples are warranted. Conversely, fewer studies examined the frequency of depression in PD samples. Zimmerman and Coryell studied a community sample of 797 individuals, OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

249

which included 143 individuals who were diagnosed with personality disorders. Among those with obsessive-compulsive PD, 31.3% met the criteria for major depression. Another large study that included 153 clients with obsessive-compulsive PD found that 75.8% had major depression (McGlashin et al., 2000). WHY DO PEOPLE WITH OBSESSIVE-COMPULSIVE PERSONALITY DISORDER GET DEPRESSED? Increased perfectionism is associated with higher levels of current depression (Hewitt & Flett, 1991a, 1991b, 1993) and increased levels of chronicity in depression (Hewitt, Flett, Ediger, Norton, & Flynn, 1998), as well as suicidality (Adkins & Parker, 1996; Hewitt, Newton, Flett, & Callander, 1997). Structural equation modeling of the relationship between perfectionism and coping (Dunkley, Blankstein, Halsall, Williams, & Winkworth, 2000) is consistent with explanations for these findings based on Lazarus's cognitive appraisal theory (Lazarus & Folkman, 1984). Perfectionism increases stress at the level of cognitive appraisal because the person evaluates nearly all performance as inadequate. In addition, perfectionists often see their selfworth as tied to their performance, thus increasing the experience of pressure. Attempting to reach goals that always seem unattainable may impact secondary appraisal, the belief that one has the resources to cope with a problem, leading to feelings of helplessness (Flett, Russo, & Hewitt, 1994). Further, perfectionism appears to interfere with coping, because perfectionists often engage in dysfunctional coping such as disengagement and denial (Dunkley, Blankstein, Halsall, Williams, & Winkworth, 2000). The strongest and most consistent finding is that individuals who have high levels of self-oriented perfectionism (in which the person is perfectionistic regarding both personal and work or achievement standards) and who encounter problems in achievement are highly prone to depression (Hewitt &L Flett, 1991a, 1991b, 1993; Hewitt, Flett, & Ediger, 1996; Z. V. Segal, Shaw, Vella, & Katz, 1992). Socially prescribed perfectionism (in which the person is concerned about what others will think if he or she is not perfect) is associated with poorer problem solving, thus indicating poorer coping (Flett, Hewitt, Blankstein, Solnik, & Van Brunschot, 1996). Individuals with higher achievement-related beliefs have been found to have depressive emotions and cognitions, specifically, "feelings of failure, self-hate, self-blame, anhedonia, guilt, irritability, loss of interest in others, and hopelessness" (Persons, Burns, Perloff, & Miranda, 1993, p. 518). There is also a substantial literature relating rumination to depression. Individuals who ruminate about their depression remain depressed more severely and for a greater duration than those who distract themselves (NolenHoeksema, 1991). In addition, a ruminative style has been found to predict depression from 30 days to 18 months later (for a review, see Spasojevic & 250

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Alloy, 2001). The mechanism by which rumination works appears to be that individuals who ruminate tend to believe that they are increasing their selfawareness and thus avoid pleasurable distracting activities (Lyubomirsky & Nolen-Hoeksema, 1993). Individuals with obsessive-compulsive PD manifest tight control to prevent the expression of anger. Prone to restraint and guilt, they turn their anger inward against the self (Millon, 1999, p. 243). Thus individuals with obsessive-compulsive PD generally fit very well with this traditional psychodynamic interpretation of depression. In addition, the internalization of the harsh, punitive parent creates a painful inner world. Although "perfect" behavior can sometimes stave off the inner critic, it always lurks in the background. Any slip—which is, of course, inevitable—creates a flood of selfrecrimination. This is often experienced as depression. I have also observed clinically that people with obsessive-compulsive PD are prone to feeling overwhelmed when their orderly lives are thrown off by uncontrollable events. Primarily, this manifests as anxiety, which is usually denied or rationalized. However, if the uncontrollable event involves loss or failure, depression often ensues. Consistent with the "vulnerability" model (see chap. 2, this volume) obsessive-compulsive PD appears to increase an individual's susceptibility to depression.

HOW A PERSON BECOMES AND REMAINS OBSESSIVE-COMPULSIVE: THEORIES OF OBSESSIVE-COMPULSIVE PERSONALITY DISORDER Biological Factors Although a good deal has been written about biological underpinnings of impulsivity, aggression, emotional dysregulation, and thought disorder, there has been little research on biological factors underlying the excessive behavioral inhibition and cognitive rigidity seen in obsessive-compulsive PD. Preliminary evidence in one study suggests that obsessive-compulsive PD features may be related to serotonergic function. However, it is not a simple relationship; insufficient serotonin has been linked to impulsive aggression, but it does not appear to be the case that excess serotonin is related to behavioral inhibition. Instead, it may be that increased serotonergic receptor sensitivity plays a role, as noted by Hollander, Decaria, Niescu, et al. (cited in Stein et al., 1996). In one small study, biological research supported psychodynamic theorizing that obsessive-compulsive PD has a component of hostility—hostility scores were higher in the obsessive-compulsive PD patients than in a mixed PD comparison group—which may emerge as impulsive aggression. Impulsive aggression scores, in turn, were associated with reduced plasma prolactin response to fenfluramine, whereas hostility scores OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

251

were associated with blunted response to fenfluramine; these findings are similar to those found with impulsive groups such as individuals with borderline or antisocial PDs (Stein et al., 1996). Further research is needed in this area to clarify the nature of neurotransmitter processing in individuals with obsessive—compulsive PD. Heritability Obsessive-compulsive PD appears to be moderately heritable. Jang et al. (1996) performed a principal component analysis of the 18 scales of the Dimensional Assessment of Personality Disorders. One of the factors, Compulsivity, is closely related to obsessive-compulsive PD. The researchers found a heritability of 44%. Torgersen, Skre, Onstad, Evardsen, and Kringlen (1993) factor-analyzed the Structured Interview for DSM-III-R Personality Disorders with a sample of index twins, co-twins, siblings, and parents and found that the Perfectionism factor had a heritability of 30%. Clifford et al. (in Nigg & Goldsmith, 1994) found that the heritability of obsessionality using the Leyton Obsessional Inventory yielded heritability estimates of .46 for males and .62 for females. A study by Coolidge et al. (2001) examined a sample of 70 monozygotic and 42 dizygotic twin pairs, ages 4 to 15, using the Coolidge Personality and Neuropsychological Inventory for Children. The heritability of obsessive-compulsive PD was 77%. One contrary finding was by Torgerson and Psychol (cited in Nigg & Goldsmith, 1994), who failed to find heritability of obsessive—compulsive traits in a mostly community twin sample; however, the scale used to measure obsessive-compulsive traits was developed for the study and had unknown psychometric properties. In a molecular genetic study, a link has been found between persistence (i.e., being hardworking, ambitious, andperfectionistic) and two genes, one of which is related to enzymatic activity and the other to serotonergic function (J. Benjamin et al., 2000). Thus it appears that obsessive-compulsive PD has heritability comparable to other PDs, and some preliminary molecular genetic work is assessing possible gene loci of associated traits. Medications An uncontrolled trial with the selective serotonin reuptake inhibitors sertraline and citalopram had mixed results (Ekselius & von Knorring, 1998; for a further description of the study, see chap. 1, this volume). The remission rate for obsessive-compulsive PD after 24 weeks of treatment was 33% for the sertraline group (ns) and 45% for the citalopram group (p < .01). The sertraline group had a mean decrease of 0.6 criterion pre- to posttreatment; the corresponding figure for the citalopram group was 1.1 criteria (p < .001 for both). Unfortunately, because there was no medication-free comparison 252

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

group, the results of the study are inconclusive; however, given the persistent nature of PDs, the finding is promising and warrants further investigation. In the absence of further data, it is worthwhile to consider Joseph's (1997) observations based on his clinical experience. He noted that characteristics such as preoccupation with details, overconscientiousness, and hoarding money are obsessional features, whereas perfectionism, excessive devotion to productivity, and requiring others to submit to one's exact way of doing things are compulsive features. He found that treatments that are effective for obsessions and compulsions (per Axis I OCD) are effective with Axis II obsessive-compulsive PD. Joseph contended that the likelihood of treatments being effective for obsessive-compulsive PD is encouraging, requiring lower doses and having a higher likelihood of success than Axis I OCD. Although clomipramine, serotonergic antidepressants, venlafaxine, and nefazodone are potentially effective treatments, serotonergic antidepressants are usually tried first because of their relatively benign side effect profile. Unfortunately, in the absence of sufficient studies, we simply do not know what medications are effective for people with obsessive-compulsive PD. In addition, I have substantial reservations about Joseph's argument that OCD and obsessive-compulsive PD lie on a continuum. The comorbidity of OCD and obsessive-compulsive PD is moderate; DSM-IV-TR noted that a majority of people with OCD do not meet the criteria for obsessive-compulsive PD. It is not clear that the two disorders, despite their shared name, have much in common (American Psychiatric Association, ZOOOa, p. 462; Millon, 1996). It may be that various antidepressants, antianxiety agents, and other medications are effective with individuals with obsessive—compulsive PD, but even if that were established, it is not clear that it is for the reasons hypothesized by Joseph. Empirical studies, ultimately leading to randomized controlled clinical trials, are needed to explore what medications are helpful in this population. Psychological Approaches Within the biopsychosocial model (Millon, 1969), psychological factors are intermediate between biological considerations (e.g., chemical and electrical reactions) and sociocultural issues (which may involve interactions of hundreds of millions of people). The psychological approaches reviewed in the following sections attend to behavioral, cognitive, affective, unconscious, and interpersonal aspects of the person's functioning. Millon's Theory According to Millon (1981, 1996) the compulsive personality is the "passive-ambivalent" type. Millon preferred the use of "compulsive" personality, rather than DSM-IV-TR's "obsessive-compulsive," to avoid confusion OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

253

with the Axis I disorder. The ambivalence refers to whether to rely on the self or on others. The compulsive character, in contrast, attempts to bind the ambivalence by appealing to rules and authority, following an external set of standards rather than listening to his or her conflicted inner voice. Though adaptive in some ways, this resolution comes at a high price: These individuals manifest extraordinary consistency, a rigid and unvarying uniformity in all significant settings. They accomplish this by repressing urges toward autonomy and independence. They comply with the strictures and conform to the rules set down by others. Their restraint, however, is merely a cloak with which they deceive both themselves and others; it serves also as a straitjacket to control intense resentment and anger Inwardly, they churn with defiance like the antisocial personality; consciously and behaviorally, they submit and comply like the dependent. (Millon, 1996, p. 506)

Yearning to assert themselves but not daring to, individuals with compulsive PD absorb themselves in daily routines and minutiae. At times, there are opportunities for the indirect expression of hostility, such as being judgmental toward those who do not comply strictly with society's rules, righteous indignation toward individuals who violate religious requirements, and so on. Direct expressions of anger in response to an individual, however, are almost unthinkable. Millon (1996) asserted that individuals with obsessive-compulsive PD were raised with extensive use of punishment and miserly amounts of praise. Parents would sternly condemn the child for any "mistakes," but behavior rarely if ever exceeded expectations or earned any reward. Consistent with the observation that individuals with obsessive-compulsive PD are indecisive, Millon noted that they become attuned to what they must not do but often are not aware of what they ought to do. More recent empirical data are consistent with this theory. An investigation of current clients' perceptions of their bond with their parents indicated that individuals with obsessivecompulsive PD reported low parental care and high overprotection (Nordahl & Stiles, 1997). Appendix B lists Millon's description of obsessive-compulsive PD in terms of the eight domains. Of the features listed, constricted cognitive style, respectful interpersonal conduct, and disciplined expressive behavior are the most salient (Millon, 1999, p. 529). Cognitive-Behavioral Conceptualization and Interventions Cognitive-behavioral therapists target thoughts such as "I must avoid mistakes to be worthwhile," "Mistakes are intolerable," and "Failure is intolerable" (A. T. Beck & Freeman, 1990, p. 315; A. T. Beck, Freeman, & Davis, 2004, p. 328). Many of Ellis's "musterbatory" statements (Ellis, 1993), such as "When I do not perform well, and win others' approval, as at all times I 254

PERSONALITY'G UIDED THERAPY FOR DEPRESSION

should, ought, and must, I am an inadequate person" (Ellis, 1997, p. 19), fall into the category of obsessive-compulsive thinking. Underlying many of these beliefs is the cognitive error of all-or-none thinking: One is either perfect or worthless, a success or a failure. Such beliefs can be treated with dysfunctional thought records and/or Socratic dialogue. The emphasis of the intervention will depend on the client's motivation. For the highly motivated client, thought records have the advantage of replacing ruminative thoughts with productive activity and establishing constructive habits through repetition. Often, individuals with obsessive-compulsive PD or features must be taught to limit the amount of material they document, selecting a few thoughts to challenge; some, using all-or-none thinking, believe they must document every thought or the exercise has been done improperly. Conversely, there are individuals with obsessive-compulsive PD who are concerned that therapy will be a waste of time or that they do not have time in their genuinely busy schedules to add homework. In such cases, 1 often start with Socratic dialogue, which does not require homework. Once the client has become familiar with Socratic dialogue, we can use it to challenge the idea that he or she does not have time to do homework. The main argument for homework is that it makes the therapy go more quickly and efficiently (efficiency—how appealing!), it can often be very brief (with practice, doing a thought record on one or two thoughts takes only a few minutes), and it can help establish habits that will be necessary for long-term maintenance of gains. If clients understand the benefits of homework and still decline, that is, of course, their prerogative. The therapeutic relationship with individuals with obsessivecompulsive PD is likely to be formal and businesslike. In cognitive-behavioral therapy, this is an acceptable position, because many of the techniques can be applied in a rather straightforward manner. The main challenge, however, is to be sure that the individual understands the benefits of treatment (because they often deny the relevance of emotions) and remains motivated to continue treatment. This is less likely to be a problem for depressed individuals with obsessive-compulsive PD because they are aware of their distress, or that something is awry. Once the depression lifts, motivation to continue to treat characterological issues is often modest or nonexistent. To avoid premature termination (thus leaving the client at high risk for relapse) it is important, at some point, to bring in how dysfunctional schemas relate to the client's depression. Timing is important, because if the client feels blamed in early sessions, he or she may leave treatment. A natural progression is for the therapist to note how distressing the client's circumstances are (e.g., feeling overwhelmed with work) and provide some ways to address this (e.g., relaxation training), followed by looking at ways to reduce the workload (e.g., assertiveness), and finally letting go of perfectionistic standards. The therapeutic goals have subtly shifted from an external orientation (e.g., "The supervisor is working me too hard") to an intermediate level ("Maybe I can OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

255

do something about it by talking to her") to a more internal focus ("It doesn't have to be perfect"). Rumination is often a serious problem for depressed individuals with obsessive-compulsive PD. Techniques such as thought stopping and distraction can be effective in such cases. In addition, worrying can be contained by suggesting "worry periods" during the day, which will help the client to let go of worries at other times. Client-Centered, Humanistic, and Existential Therapies Although there is little humanistic client-centered literature specific to obsessive-compulsive PD per se, the experiential background of the person with obsessive-compulsive PD is a classic example of what Rogers would call "conditions of worth" (see Rogers, 1979). Millon (1996) described the overcontrolling parenting style that predisposes one to obsessive—compulsive PD: They learn what they must not do, so as to avoid negative reinforcements. . . . Compulsives learn to heed parental restrictions and rules; for them, the boundaries of disapproved behaviors are rigidly set. However, as a function of experiencing mostly negative injunctions, they have little idea of what is approved; they seem to know well what they must not do, but do not know so well what they can do. (p. 531) In theory, a form of therapy that emphasizes consistent unconditional positive regard would be a direct antidote to the persistent negative attention such individuals received as children. It is likely that the person with obsessive-compulsive PD would chafe at the unstructured nature of the treatment and would initially impose his or her own structure but would gradually come to appreciate the persistent open and accepting stance of the therapist. Psychodynamic Therapy There is a long history of treatment of obsessive-compulsive PD with psychodynamic therapy. What we now call obsessive—compulsive PD is akin to the "anal character" (Abraham, 1953/1997; Freud, 1908/1959) based on Freud's anal phase of development; that is, the problem of the obsessivecompulsive person is thought to be rooted in fixation at the anal phase of development. This fixation can be caused by excessive libidinal energy affixed to the anus (anal eroticism) or to issues relating to toilet training. More relevant than toilet training per se are the associated symbolic meanings that are being learned by the child or negotiated between parent and child, namely, dirtiness versus cleanliness, learning self-control, the ability of the child to defy his or her parents (e.g., by expelling or withholding urine or feces), and so on. According to psychodynamic theory, superficial compliant behavior is a cover for underlying hostility: 256

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

The traits of overcontrol and inhibition of expression of aggression are clinically observed to be compensatory defenses against the underlying sadistic thoughts and fantasies. The underbelly of pleasurably charged raw aggression is readily seen in the play and dreams of [obsessivecompulsive PD] children, in dramatic contrast to their constricted behavior in public. (P. Kernberg, Weiner, & Bardenstein, 2000)

Such children become filled with rage over minor disruptions in routine. Their attempt to maintain control is deleterious to both family and peer relationships. Intervention consists of confronting the defenses against the underlying rage, fear, and anxiety. The goals of treatment for obsessive-compulsive PD were concisely stated by P. Kernberg et al. (2000): Psychodynamic treatment of [obsessive-compulsive PD] seeks to transform maladaptive automatic, ego-syntonic behavior and thought processes compatible with the patient's sense of self into ego-dystonic or incompatible behavior and thought processes that the patient can readily identify, recognize as maladaptive, and then resolve. Psychodynamic approaches focus on the conflict underlying and giving rise to the [obsessive-compulsive PD] trait, toward helping the patient deal with the unacceptable wish and fear in direct, adaptive ways. (p. 123)

P. Kernberg et al. gave the example of a child who is refusing to go to a party because it will be "boring"; the goal of psychodynamic therapy would be to help the child become aware of the underlying fear (e.g., of rejection) or rage (e.g., against those who would reject him) and also to let go of the denial of feelings (i.e., saying that it will be boring, with no apparent involvement of feelings as opposed to being overwhelmed with emotion). Typical defensive operations among individuals with obsessive—compulsive PD include reaction formation, isolation of affect, rationalization, and displacement. (P. Kernberg et al., 2000, p. 123) Transference issues often reflect the ambivalence of the client regarding dominance and submission. The therapeutic relationship is generally impacted by the client's character pathology. L. S. Benjamin (1996a) gave a fine example: A patient was very slow to recognize that he was depressed. He thought he could stay "on top of" the problem if only he could get things better organized. But the signs of depression persisted, and suddenly one day the patient admitted he was depressed. Then he was willing to take the prescription, but looked it up in the [Physicians Desk Reference] in order to be aware of possible side effects. The depression continued. The patient sent the doctor reprints on recent studies of antidepressants and questioned the prescription. The patient expressed frustration that the right medication had not been found. He alternated between deferring

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

257

to the doctor's opinion about what to do next and blaming the doctor for not doing better, (p. 248) Clinicians must be prepared for ambivalence and anxiety-driven maneuvering. The symptoms can be confronted directly in the here and now or can be connected to earlier object relations, particularly with the parents. Family Systems Individuals with obsessive-compulsive PD often partner with individuals with histrionic PD. For a discussion of the histrionic/obsessive-compulsive couple, see chapter 9, this volume, on histrionic PD. Group Therapy Individuals with obsessive—compulsive PD can be difficult to treat in group therapy. They tend to align with the therapist, deny that they have any problems, and shut out any emotions, thereby failing to process their emotions in a group format—and perhaps disrupting the group process. Nonetheless, psychodynamically informed expressive-supportive therapy was found to be effective for a group of individuals with obsessive-compulsive PD. Barber Morse, Krakauer, Chittams, and Crits-Cristoph (1997) found that at the end of 52 weeks of treatment, 85% of the patients in group therapy no longer met the criteria for the disorder; depression and other problems were ameliorated as well. In theory, other expressive techniques could be useful to break through the obsessive-compulsive person's emotional deadlock. Experiential techniques that re-create emotionally intense experiences could potentially help the individual to connect with some emotional experiences. There is a risk that the individual can become highly anxious if overstimulated, so therapeutic judgment must be exercised in weighing the costs and benefits of treatment. My impression is that in most cases of obsessive—compulsive PD— not just some features, but the full-blown diagnosable disorder—it would be best to defer group therapy until the client has made some progress in individual or family therapy. If the individual can be better described as having a mixed obsessive-compulsive and dependent PD—a fairly common subvariant—then prospects are better (Bockian, 1990). Such individuals are more compliant, less stubborn, less filled with doubt, and more trusting. This combination allows the client to more easily take advantage of the group process.

COUNTERTRANSFERENCE Individuals with obsessive-compulsive PD typically present material in a dry, unemotional way, which elicits feelings of boredom. Their excessive focus on details, which can slow progress substantially, can be exasperating

258

PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON

to clinicians. They may also make efforts to control therapy sessions, thereby provoking frustration from clinicians (A. T. Beck et al., 2004). Research was conducted on graduate students, in which they rated their emotions in response to a video of an interview between a clinician and a client simulating obsessive-compulsive PD (Bockian, 2002a; see chap. 1, this volume, for a further description of the study). The issues noted by A. T. Beck et al. (2004) and reviewed above were supported and extended. Findings suggest that participants responded to individuals with obsessivecompulsive PD in three discernable patterns. One pattern was frustration (irritation and exasperation), presumably in response to the client's focus on detail and emotional constriction. Another pattern was to express compassion (empathy, sadness, and pity); the empathic feelings were probably related to general therapeutic feelings, whereas the pitying feelings appeared to be related to comparisons that participants made between the client's current constricted emotional life and a more "ideal" emotional and related way that he could be. Finally, the third pattern of emotional response was feelings of disconnection (guardedness and dullness), which also appeared to be related to the client's nonrelational and unemotional style. Depending on the severity of the disorder, these emotions resonate well with my own experience of treating people with obsessive-compulsive PD. In the case of Ronald, presented below, I felt extremely disconnected and at times frustrated. With others with obsessive- compulsive PD, I have at times felt pity because their lives seemed so regimented and constricted as to be no fun at all; this has been particularly true of individuals with obsessivecompulsive PD and depression. As noted in earlier chapters in this book, pity is a potentially problematic countertransference, and I take a variety of precautions and countermeasures to resolve such feelings (see the countertransference section of chap. 11, this volume, on avoidant PD). Maintaining a connection can be a real challenge with a person with obsessive-compulsive PD, particularly if one is feeling irritated, disconnected, or dull (bored). Patience is often the key. Working through problems slowly and methodically is suited to the individual's style. Internally, I try to stay present in the moment and to continuously empathize with the client. Sometimes, I am able to maintain my patience, but the client's wears thin. Whether it is the therapist, the client, or both who are struggling, supervision or peer consultation (for the therapist) can be very helpful.

SOCIAL CONSIDERATIONS AND DIVERSITY The excess of males with obsessive-compulsive PD is consistent with male dominance in the social hierarchy of Western cultures (Castillo, 1997). Individuals with obsessive-compulsive PD tend to be obsequious toward superiors and demanding of subordinates and are thus highly aware of domi-

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

259

nance hierarchies. In certain cultures, obsessive—compulsive characteristics may be seen as strengths, particularly by the religiously devout, among whom scrupulous attention to the details of religious observance may be seen as right and appropriate behavior. In the United States, religious behavior that might appear to be symptomatic of obsessive-compulsive PD may be normative within that reference group. For example, Galanti (cited in Castillo, 1997) described a case of an Orthodox Jewish man who brought his wife to the hospital while she was in active labor on the Sabbath. According to the requirements of halacha (Jewish law), he could not purchase food in the cafeteria, handle money, or operate electrical devices (e.g., push the button on the elevator or turn on the TV). These same rules would be followed by any Orthodox Jew, regardless of personality type, and therefore do not indicate obsessive—compulsive PD symptoms. Obsessive—compulsive PD appears to be one of the more prevalent PDs in populations of older adults (Devanand et al., 2000). Dimensional ratings suggest that although overall personality and clinical dysfunction is lower in older adults than in younger adults, older adults have elevations on obsessive-compulsive PD scales (D. L. Segal, Hook, & Coolidge, 2001). It is not clear, however, whether these findings are due to cohort effects (e.g., values more prevalent in prior generations), whether people tend to become more obsessive-compulsive as they age, or if they can be accounted for by other factors (e.g., economic considerations or other circumstances that differentially impact older adults). Longitudinal research would be necessary to clarify these issues.

STRENGTHS OF PERSONS WITH OBSESSIVE-COMPULSIVE PERSONALITY DISORDER Individuals with obsessive-compulsive personality style or features have a variety of strengths. Diligence, persistence, and a proclivity to work hard toward one's goals are highly desirable characteristics in U.S. culture, as are being organized, efficient, and productive. Witticisms from Ben Franklin dating back over 200 years capture these values (e.g., "early to bed and early to rise . . ."). A variety of awards recognize achievement and symbolize our admiration for individuals who have been successful. In most cases, such levels cannot be achieved by talent alone; hard work is necessary. Depressed individuals with obsessive-compulsive PD can draw on those strengths during the process of recovery. It is reliably true that the most detailed charts and most scrupulous tracking of behavioral assignments will occur in the somewhat obsessive-compulsive client. Research using the Millon Clinical Multiaxial Inventory—II (MCMIII; Millon, 1987a) has shown that when individuals have a primary elevation on the Obsessive-Compulsive scale and a secondary elevation on the Nar260

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

cissistic scale, the overall profile tends to be in the nonpathological range; this finding suggests that the obsessive-compulsive tendency toward hard work and humility, combined with a belief in one's own ideas, is a relatively healthy pattern. It is interesting to note that when the Narcissistic scale was primary and the Obsessive-Compulsive scale was secondary, the entire profile had a variety of elevations and was moderately pathological; perhaps if one is not willing to put in the work to back up one's ideas, problems begin to surface. Thus in some (though not all) cases of obsessive-compulsive personality, there are healthy feelings of humility. In addition, a combination of histrionic and obsessive—compulsive features was related to low overall MCMI-II elevations, indicating a relatively healthy adjustment. A capacity to be outgoing and fun loving while also being able to work hard and maintain moral boundaries is a very adaptive combination (Bockian, 1990). These personality styles (combinations of adaptive obsessive-compulsive, histrionic, and narcissistic features) seem common in professionals. A certain amount of obsessive-compulsive style is necessary for the rigors of training and maintaining proficiency; a presentational flair is important for teachers, professors, and trial attorneys, among others; and confidence is helpful for achieving success in nearly any profession.

TREATMENT PLANNING: SYNERGISTIC TREATMENT As with most treatment of individuals with PDs, there are challenges to the establishment of a therapeutic bond with the person with obsessivecompulsive PD; this is less prominent when depression is simultaneously present, because the client is unlikely to deny that there is a problem. A client-centered approach emphasizing warmth, unconditional positive regard, and accurate empathy facilitates the formation of a therapeutic alliance. Consistent with the client's personality, formulation of goals should begin as soon as possible, preferably in the first session. Behavioral techniques such as relaxation training and thought stopping can provide relatively quick relief from tension and enhance motivation to comply further with treatment. The behavioral interventions blend well with cognitive and interpersonal approaches. Cognitive interventions can be extremely helpful and highly ego syntonic for the client, who generally believes that all problems have a rational solution. Interpersonal therapy can help clients to address issues that arise with others in their environments; often, they will see their problems as being a function of others' demands, so interpersonal conceptualizations are also likely to fit well with their worldview. Medications should be introduced judiciously, because early relief from pharmacological agents may facilitate premature termination. Couples interventions can be essential, especially in the case of the obsessive-compulsive/histrionic marriage (as illustrated in chap. 8, this volume), and in some cases, OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

261

EXHIBIT 12.1

Therapeutic Strategies and Tactics for the Prototypal Compulsive Personality STRATEGIC GOALS Balance Polarities Identify and stabilize self-other conflict Encourage decisive action Counter Perpetuations Loosen pervasive rigidity Reduce preoccupation with rules Moderate guilt and self-criticism TACTICAL MODALITIES Alter constricted cognitive style Adjust perfectionistic behaviors Brighten solemn-downcast mood Note. From Personality-Guided Therapy (p. 535), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

sexual counseling may be helpful for an excessively constricted client. Psychodynamic interventions also can be helpful, because these individuals are able to focus on the details of their experience; interpretation can then help them to synthesize what they experience as countless unique phenomena into a more cogent whole. An overview of a personality-guided approach to obsessive—compulsive PD is provided in Exhibit 12.1.

CASE EXAMPLE: RONALD The following case uses personality-guided therapy in a behavioral medicine setting. There are some advantages and limitations to treatment of PDs in this setting. Some patients respond extremely rapidly to therapy, in part because of the medical crisis that sometimes creates a strong motivation for change and in part because of unique relationships that are available in medical cases. The availability of a large number of patient-staff contacts in the medical setting can provide a context for rapid change (see, e.g., the case example in chap. 7, this volume). In the case below, Ronald experienced egosyntonic personality and depressive symptoms and probably never would have seen me were it not for the urging of a fellow hospitalized patient; relationships among patients can be another powerful catalyst for change. However, when change does not occur rapidly, there is often little opportunity to extend treatment. Ronald was discharged once his medical treatment was done, which gave us about 10 weeks to work together. 262

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Ronald was a 38-year-old married Army veteran when I saw him. He had paraplegia and used a wheelchair to ambulate. Ronald was admitted to the spinal cord injury service for a decubitus ulcer, which is caused by excessive duration of pressure on the tissues under the pelvic bones. Individuals with spinal cord injury usually must spend some time out of their wheelchairs to take pressure off of sensitive areas. I did a routine intake with Ronald, who had a number of difficulties, described below. After the intake, he was not interested in psychotherapy. However, Ronald was experiencing chronic pain secondary to his spinal cord injury; he was referred to me by a fellow spinallyinjured veteran whom I had treated for a pain problem using hypnosis. On intake, I learned that Ronald worked approximately 60 hours per week, five 12-hour days, including over an hour commute by car in each direction. Ironically, Ronald worked as a paralegal for a law firm that handled numerous disability rights lawsuits under the Americans with Disabilities Act; thus, one would have thought they would be understanding of his special needs. Nonetheless, from Ronald's perspective, his boss was demanding, and Ronald did not dare even ask for a lighter work schedule or other accommodations. It is likely, however, given Ronald's obsessive tendencies, that his work took him far longer than it should have. Ronald was anxious that he would lose his job if he made any waves. Ronald's relationship with his wife seemed rather cold and distant. His Italian American background made his behaviors and attitudes more striking, because that subculture is generally characterized by warmth, closeness, and emotional expressiveness (Giordano & McGoldrick, 1996). He identified mainly as an American and did not seem to draw much from his Italian heritage. Hospitalization seemed extremely comfortable to Ronald. He remained in bed, uncomplaining, reading his newspaper and appearing quite content. It appeared that Ronald was getting the rest and nurturance that was sorely lacking in other areas of his life. Ronald's primary defense mechanism was intellectualization. Perhaps the most striking aspect of the case occurred during our first session, at which I discussed his medical condition with him. Decubiti (also known as "pressure sores") have a large behavioral component; they can almost always be prevented through behavioral interventions, such as pushing on armrests every few minutes to allow blood flow to the tissue beneath the hip pointers and avoiding excessive sitting times. Ronald's response sounded as if I were talking about another person. "How interesting," he commented as I provided psychoeducation, including a discussion of consequences that most clients consider dire. Without adequate pressure relief, the tissue dies; surgical corrections usually work the first time but become progressively more likely to fail. Ultimately, the damage cannot be healed, and the patient can no longer ambulate in a wheelchair, effectively rendering him or her bedbound and, implicitly, either homebound or institutionalized. Ronald's expression did OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

263

not change at all; he had no apparent emotional reaction. If he had heard any of this information before, he did not say so. I actually felt a chill go through my body—a kind of instinctive recoiling from the deadness and disconnection from affect; though it is difficult to put into words what I was experiencing, it might best be described as a momentary kind of existential dread. Ronald had two core beliefs underlying his cognitions, namely, the beliefs that he was helpless and worthless. Unpacking the meaning of these beliefs was complex as a result of the stigmatizing impact of spinal cord injury. Ronald believed that he could not get a new job because of the stigma against individuals with spinal cord injury. Sadly, it is clear that there is discrimination against individuals with spinal cord injury in the workplace, as seen in the 76% unemployment rate (compared with 39% preinjury) documented by the Annual Report for Model SCI Care Systems (cited in Krause & Anson, 1997). Ronald's belief had a strong potential basis in reality. However, Ronald would not perform the behavioral experiment of trying to get a new job. Also, individuals who experience the stigma of spinal cord injury who are not particularly prone to depression (e.g., externalizers) become angry rather than depressed. "If only they would give me a chance" or "It is unfair and illegal" are their usual battle cries. This was not Ronald's response. He internalized the negative feelings, becoming dysthymic. The worthlessness belief fed the helplessness beliefs; it is as if he were saying, Because I am worthless, no one would want to hire me. I cannot stand up to anyone, because I am powerless and have nothing to offer. All I can do is work as hard as I can to try to show that I have some value.

Ronald's response was consistent with Castillo's (1997) conceptualization of the conforming response to a stigmatized moral career. Unfortunately, Ronald was not motivated to challenge these beliefs. He did not see them as modifiable; rather, he saw them simply as reality. Though somewhat skeptical, Ronald was more open to viewing his pain as something that could be modified. I saw him weekly for hypnotic sessions. Although the literature generally shows no correlation between personality and hypnotizability, in this case the client's rigidity and difficulty "letting go"—which I saw as components of his obsessive-compulsive PD—slowed progress in hypnosis. However, as compensation, Ronald was diligent in doing his homework, practicing with tapes of our hypnotic sessions. After approximately seven or eight sessions, he experienced about a 25% reduction in his pain experience. Although this was a below-average result,2 it was still a substantial improvement for him. 2

At the time, my typical result using hypnosis for pain was a 33% to 66% reduction on self-rated pain. 264

PERSONALITY-GUIDED THERAPY FOR DEPRESSION

Ronald's progress with his pain provided a natural challenge to his helplessness belief. His feelings of efficacy improved, and his confidence grew. He was somewhat less depressed. However, his beliefs that he was worthless could not be sufficiently challenged in this intervention. The pain management work provided an entree into treatment in this case. By the end of the 10 weeks, we had a solid working alliance that I believe would have laid the groundwork for addressing Ronald's problematic behaviors and attitudes. A great deal more time would have been required, however, to challenge his feelings of worthlessness and the probable secondary gain from hospitalization. To the extent that he did improve, taking advantage of his personality strengths (e.g., diligence) and being patient with his personality problems (e.g., rigidity) were important to his progress.

SUMMARY AND CONCLUSIONS As demonstrated in the case example, working with depressed individuals with obsessive—compulsive PD often requires a good deal of patience. Fortunately, if a good therapeutic bond is established, such clients can be very persistent. It is critical to establish initial rapport, which involves carefully titrating warmth and genuineness with the client's need for distance. Cognitive-behavioral approaches often fit well with these individuals' desire for tangible, task focused interventions. Later, humanistic or psychodynamic approaches, focusing on the "here and now" of the therapeutic relationship, can enhance progress. Family systems therapy may be essential when the client's rigidity distances significant others. A substantial amount of additional research is needed for obsessivecompulsive PD and its relationship with depression. Biological factors in obsessive-compulsive PD are poorly understood; of course, then, interactions between obsessive-compulsive PD and depression are even less understood. Medication interventions for obsessive-compulsive PD are in their infancy; little empirical work has been done, and I have significant reservations about existing theory. Prospective studies assessing how obsessive—compulsive PD develops, and cross-sectional studies to assess the relationship between childhood precursors of it and associated theory-derived risk factors (e.g., the correlation between perfectionism and being exposed to a demanding parenting style) would be a major contribution. Further work should also explore the nature of the interaction between depression and obsessive—compulsive PD, such as whether depression improves motivation for treatment and how improvements in one disorder lead to improvements in the other.

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

265

APPENDIX A: EMOTION LIST—2 Age

Gender

Date

Code (1st initial of first name and last 4 of SS#) Religion (circle one): Protestant, Catholic, Jewish, Muslim, Hindu, Buddhist, other . Race/Ethnicity (circle one: White, African American, Hispanic, Asian, Native American, other). Clinical Experience: Number of years of full-time experience, master's level or above, excluding practica, doing psychotherapy or diagnostic work (use fractions if necessary) Number of years of practicum experience you have (use fractions if necessary) Have you seen this film clip before? Yes No Please rate how much you experienced each of the following emotions in response to the client you encountered. In common language, you might say "the client 'made me feel .'" You might think of this as how strongly a client "pulls for" a particular emotion. If you can explain why you felt a particular emotion/emotions, or can provide clarification of what you were imagining or other contextual information, please do so on the back of the form.

Use the following scale: 1=1 did not respond this way at all, to 5 = I felt this very much 1. Angry 2. Hostile 3. Animosity 4. Hatred 5. Exasperated 6. Manipulated 7. Revulsion 8. Repulsion 9. Happy 10. Contented 11. Joyful 12. Gladdened 13. Hopeful

14. Confident 15. Reassured 16. Expectant 17. Attracted 18. Charmed 19. Infatuated 20. Enamored 21. Fascinated 22. Curious 23. Amused 24. Sad 25. Unhappy 26. Melancholy 267

27. Downhearted 28. Morose 29. Dispirited 30. Despondent 31. Depressed 32. Dejected 33. Blue 34. Heavy 35. Downcast 36. Energized 37. Enlivened 38. Excited 39. Inspired 40. Encouraged 41. Frustrated 42. Suffocated 43. Drained 44. Sucked dry 45. Pent-up 46. Belittled 47. Ashamed 48. Embarrassed by 49. Embarrassed for 50. Humiliated 51. Pity 52. Compassion 53. Sympathy 54. Empathy 55. Understanding 56. Connected 57. Emotional identification 58. Responsible for 59. Protective 60. Rescuing 61. Burdened 62. Guilty 63. Appeasing 64. Trying to please 65. Deferential 66. Frightened 67. Fearful 68. Afraid 69. Apprehensive

268

APPENDIX A

70. Defensive 71. Guarded 72. Alarmed 73. Threatened 74. Scared 75. Intimidated 76. Terrified 77. Anxious 78. Nervous 79. Distressed 80. Dreading 81. Agitated 82. Irritated 83. Bored 84. Dull 85. Apathetic 86. Wearied 87. Fatigued 88. Tired 89. Worn out 90. Sleepy 91. Confused 92. Perplexed 93. Baffled 94. Bewildered 95. Weird

96. Odd 97. Surreal 98. Disconnected 99. Disconcerted 100. Flustered 101. Overwhelmed 102. Confounded 103. Dismayed 104. Edgy 105. Tenuous 106. "Walking on eggshells" 107. Like/Liking 108. Dislike Tension in the: 109. neck 110. shoulders 111. back

112.throat 113. leg 114. arm 115. other

116. Feeling choked or unable to breathe 117. Heart rate increase 118. Sexual arousal Pain or ache in the; 119. neck 120. shoulders 121. back 122. throat 123. leg 124- arm

125. other

126. Leaning forward 127. Leaning back 128. Arms crossed 129. Legs crossed Heavy feeling in the: 130. neck 131. shoulders 132. back 133. throat 134. leg 135. arm 136. other

Explanation of emotional response: if you can, please provide an explanation or context for the emotions you felt, or add any other information. Please add any additional words, and how strongly you felt this way, here.

APPENDIX A

269

X

271 Constricted

u

"c o O

Deferential

Secretive

Paradoxical

Provocative

Eccentric

Spasmodic

Defensive

ncompatible Unalterable

Inviolable

CD

t

CC

0

CD

c g

E 15

"5.

b

V)

0)

u

o w !£

_

CO

CD O)

en

CO X LLJ

to

O O

c

o

73 C

D

-o

ragmente

Inverted

"D. cy>

Inelastic

O)

o:

Suspicious

o 15 co E

CD

"c

Melancholic

Anguished J

Apathetic

Mood/ emperament

Callous

Insouciant

Distraught or insentient

Dysphoric

Irritable

Solemn

Irascible

-CD

Paranoid

Uncertain

§

Capricious

§

Borderline

Chaotic

Estranged

CO Q.

Divergent

•c

Autistic

Eruptive

•o CD .bJ

Schizotypa

Discredited

Undeserving

Spurious

Disjointed

Inchoate

Depleted

c

Diffident

CO

Abstinent

Vacillating

Discontented

"o

15 o

Resentful

D)

c o

CD

Negativisti

Concealed

Conscientious

"5 o

Respectful

Debased

c

Disciplined

CO

Pernicious

c

Combative

c g

Autonomous

differentia CD

Skeptical

Deviant Dogmatic

O>

Abrasive

Q

Irresponsible

£:

Impulsive

0

Precipitate

CO

Rational!.,

'2

15

E c

1o o X

Compulsiv

Contrived

Admirable

O) UL

!c

Expansive

c

Exploitive

c g

Dissoci;

H

Attentionseeking

CO

c g

Antisocial

Shallow

Gregarious

Submissive

Incompetent

u_ o

.CD

Sadistic

Immature

Defenseless

CD

Disconsolate

Intellectua CO UCO 0

CO Q.

Narcissist!

Forsaken

Worthless

Pessimistic

'5

CD TO CO CD

>, a c

Histrionic

Vexatious

Alienated

'c ">•

Distracted

0 Q. CD

Aversive

co (0

Complacent

w E O)

0)

Impoverished _N

Dependent

a

Unengaged

DC

HJ

Impassive

o IA c g a LL

Depressive

p-1 E 0

Avoidant

CO CO P =

Schizoid

CO orpholog rganizatic

O p^ U

Regula Mechan

O Object presentatio

CO

Expressive Interpersonal Acts Conduct

co

Domain/ Disorder

H .y 'o

H

c o 'co c g

o O

CO CD

'Q ol

C7> o C, "O _0>

O CO

.85

REFERENCES Abraham, K. (1983). The influence of oral eroticism on character-formation. In T. Millon (Ed.), Theories of personality and psychopathology (3rd ed., pp. 128133). New York: Holt, Rinehart & Winston. (Original work published 1924) Abraham, K. (1986). Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. In J. C. Coyne (Ed.), Essential papers on depression (pp. 31-47). New York: New York University Press. (Original work published 1911) Abraham, K. (1997). Contributions to the theory of the anal character. In D. J. Stein & M. H. Stone (Eds.), Essential papers on obsessive-compulsive disorder (pp. 370392). New York: New York University Press. (Original work published 1953) Abramson, L. Y., Seligman, M. E. P., &. Teasdale, J. D. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology ,87, 4974. Ackerman, N. W. (1958). The psychodynamics of family life. Oxford, England: Basic Books. Adkins, K. K., & Parker, W. (1996). Perfectionism and suicidal preoccupation, journal of Personality, 64, 529-543. Adler, G. (1985). Borderline psychopathology and its treatment. New York: Jason Aronson. Agor, W. D. (2005). Emotional response patterns as a clinical indicator for personality disorders: The passive aggressive personality. Unpublished manuscript. Agor, W. D., Smith, J., & Bockian, N. R. (2005, August). Emotional response patterns as a clinical indicator for personality disorders: The passive aggressive personality. Poster presented at the Annual Convention of the American Psychological Association, Washington, DC. Akhtar, S. (1987). Schizoid personality disorder: A synthesis of developmental, dynamic, and descriptive features. American journal of Psychotherapy, 41, 499— 518. Akhtar, S. (1992). Broken structures: Severe personality disorders and their treatment. London: Jason Aronson. Akhtar, S., & Thomson, J. A., Jr. (1982). Overview: Narcissistic personality disorder. American Journal of Psychiatry, 139, 12—20. Alberti, R., & Emmons, M. (1978). Your perfect right. San Luis Obispo, CA: Impact Publishers. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.

273

American Psychiatric Association. (1990). The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging: A task force report. Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (ZOOOa). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2000b). Practice guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, J57(SuPPl. 4), 1-45. Anderson, C. M., Hogarthy, G., & Reiss, D. J. (1980). Family management of adult schizophrenic patients: A psychoeducational approach. Schizophrenia Bulletin, 6, 490-505. Anderson, I. M. (1998). SSRI versus tricyclic antidepressants in depressed inpatients: A meta-analysis of efficacy and tolerability. Depression and Anxiety, 7(Suppl. 1), 11-17. Anderson, K. G., Sankis, L. M., & Widiger, T. A. (2001). Pathology versus statistical infrequency. Potential sources of gender bias in personality disorder criteria. Journal of Nervous and Mental Disease, 189, 661-668. Anderson, T. (2000). Integrating research and practice in psychotherapy. In S. Soldz & L. McCullough (Eds.), Reconciling empirical knowledge and clinical experience: The art and science of psychotherapy (pp. 83-98). Washington, DC: American Psychological Association. Arkowitz, H., & Messer, S. (Eds.). (1984). Psychoanalytic and behavior therapy: Is integration possible? New York: Plenum Press. Auranen, M., Vanhala, R., Varilo, T., Ayers, K., Kempas, E., Ylisaukko-Oja, T., et al. (2002). A geiiomewide screen for autism-spectrum disorders: Evidence for a major susceptibility locus on chromosome 3q25-27. American journal of Human Genetics, 71, 777-791. Bachar, E., Kindler, S., Schefler, G., & Lerer, B. (1991). Reminiscing as a technique in the group psychotherapy of depression: A comparative study. British Journal of Clinical Psychology, 30, 375-377. Bailey, A., LeCouteur, A., Gottesman, L, Bolton, P., Simonoff, E., Yuzsas, E., & Rutter, M. (1995). Autism as a strongly genetic disorder: Evidence from a British twin study. Psychological Medicine, 25, 63-77. Bandura, A. (1977). Social (earning theory, Englewood Cliffs, NJ: Prentice Hall. Barber, ]., P., Morse, J. Q., Krakauer, I. D., Chittams, ]., & Crits-Chnstoph, K. (1997). Change in obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy. Psychotherapy: Theory, Research, Practice, Training, 34, 133-143. Basoff, E. S., & Glass, G. V. (1982). The relationship between sex roles and mental health: A meta-analysis of twenty-six studies. Counseling Psychologist, 10, 105112. 274

REFERENCES

Bateson, G. (1972). Steps to an ecology of mind. New York: Ballantine Books. Baucom, D. H., Shoam, V., Mueser, K. T., Daiuto, A., & Stickle, T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology, 66, 53-88. Beach, S. R. H., &. Jones, D. J. (2002). Marital and family therapy for depression in adults. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 442-440). New York: Guilford Press. Beck, A. T. (1967). Depression. New York: Harper & Row. Beck, A. T. (1983). The development of depression: A cognitive model. InT. Millon (Ed.), Theories of personality andpsychopathology (pp. 247-256). New York: Holt, Rinehart & Winston. Beck, A. T., & Freeman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford Press. Beck, A. T., Freeman, A., & Davis, D. D. (2004). Cognitive therapy of personality disorders (2nd ed.). New York: Guilford Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Beck, J. S. (2003, August). A cognitive approach. In J. J. Magnavita (Chair), Current perspectives and future directions for treating personality disorders. Symposium conducted at the American Psychological Association Convention, Toronto, Ontario, Canada. Behind the verdict. (1995, October 7). Economist, 7935, 27-28. Benazon, N. R. (2000). Predicting negative spousal attitudes toward depressed persons: A test of Coyne's interpersonal model, journal of Abnormal Psychology, 109, 550-554. Bendetti, F., Szforzini, L., Colombo, C., Marrei, C., &Smeraldi, E. (1998). Low-dose clozapine in acute continuation treatment of severe borderline personality disorders. Journal of Clinical Psychiatry, 59, 103—107. Benjamin, J., Osher, Y., Lichtenberg, P., Bachner-Melman, R., Gritsenko, L, Kotler, M., et al. (2000). An interaction between the catechol O-methyltransferase and serotonin transporter promoter region polymorphisms contributes to tridimensional personality questionnaire persistence scores in normal subjects. Neuropsychobiology, 41, 48-53. Benjamin, L. S. (1996a). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). New York: Guilford Press. Benjamin, L. S. (1996b). Introduction to the special section on structural analysis of social behavior, journal of Consulting and Clinical Psychology, 64, 1203-1212. Berger, D. (1971). In search of the animus. Comprehensive Psychiatry, 12, 277-286. Betan, E., Heim, A. K.( Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American journal of Psychiatry, 162, 890-898. REFERENCES

275

Black, L. (1996). Families of African origin: An overview. In M. McGoldrick & J. Giordano (Eds.), Ethnicity and family therapy (2nd ed., pp. 57-65). New York: Guilford Press. Black, D. W., Monahan, P., Wesner, R., Gabel, J., & Bowers, W. (1996). The effect of fluvoxamine, cognitive therapy, and placebo on abnormal personality traits in 44 patients with panic disorder. Journal of Personality Disorders, 10, 185-194Blatt, S. J. (1974). Levels of object representation in anaclitic and introjective depression. Psychoanalytic Study of the Child, 29, 107-157. Blatt, S. J., Shahar, G., & Zurhoff, D. C. (2002). Anaclitic/sociotropic and introjective/ autonomous dimensions. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 315-333). London: Oxford University Press. Bockian, N. R. (1990). Personality disorder subtypes: Criterion and theory based. Unpublished doctoral dissertation, University of Miami, Coral Gables, FL. Bockian, N. R. (1994). Systemic-behavioral treatment of a personality disorder and abusive behavior on a spinal cord injury unit: A case illustration. SCI Psychosocid Process, 7, 153-160. Bockian, N. R. (1999, September). Masculinity and spinal cord injury. Paper presented at the 13th annual conference of the American Association of Spinal Cord Injury Psychologists and Social Workers, Las Vegas, NV. Bockian, N. (2001, December). Teaching students awareness and constructive use of their emotional reactions to clients. Paper presented at the Argosy University Academic Conference, Chicago, IL. Bockian, N. (2002a, October). Self-awareness, countertransference, and the MCMI— III personality disorders. Paper presented at the 9th annual Millon Conference on Personology and Psychopathology, Minneapolis, MN. Bockian, N. (2002b, April). Teaching about therapist emotional reactions (countertransference): Multiple theoretical perspectives. Poster presented at the Western Psychological Association Convention, Irvine, CA. Bockian, N., Dill, W., Fidanque, C., & Lee, A. (1999, September). Personality and quality of life in an SCI/medical sample. Poster presented at the American Association of Spinal Cord Injury Psychologists and Social Workers Annual Conference, Las Vegas, NV. Bockian, N. R., & Jongsma, A. E. (2001). The personality disorders treatment planner. New York: Wiley. Bockian, N. R., Porr, V., & Villagran, N. E. (2002). New hope for people with borderline personality disorder. Roseville, CA: Prima Publishing. Bogenschutz, M. P., & Nurnberg, H. G. (2004). Olanzapine versus placebo in the treatment of borderline personality disorder. Journal of Clinical Psychiatry, 65, 104-109. Boland, R. J., & Keller, M. B. (2002). Course and outcome of depression. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 43-60). New York: Guilford Press.

276

REFERENCES

Bornstein, R. F. (1996). Sex differences in dependent personality disorder prevalence rates. Clinical Psychology: Science and Practice, 3, 1-12. Bornstein, R. F. (2005). The dependent patient: A practitioner's guide. Washington, DC: American Psychological Association. Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry, 7, 345-374. Broadwell, S. E. (1998). The effects of mindfulness meditation training on medical residents. Unpublished manuscript. Brody, E. M., & Farber, B. (1996). The effects of therapist experience and patient diagnosis on countertransference. Psychotherapy, 33, 372-380. Buchsbaum, M. S., Nenadic, I., Hazlett, E. A., Spiegal-Cohen, J., Fleischman, M. B., Akhavan, A., et al. (2002). Differential metabolic rates in prefrontal and temporal Brodmann areas in schizophrenia and schizotypal personality disorder. Schizophrenia Research, 54, 141-150. Buchsbaum, M. S., Yang, S., Hazlett, E., Siegel, B. V., Germans, M., Haznedar, M., et al. (1997). Ventricular volume and asymmetry in schizotypal personality disorder and schizophrenia assessed with magnetic resonance imaging. Schizophrenia Research, 27, 45-53. Burbach, F. R. (1996). Family based interventions in psychosis—an overview of, and comparison between, family therapy and family management approaches, journal of Mental Health, 5,111-134. Buxbaum, J. D., Silverman, ]. M., Smith, C. ]., Kilifarski, M., Reichert, J., Hollander, E., et al. (2001). Evidence for a susceptibility gene for autism on chromosome 2 and for genetic heterogeneity. American Journal of Human Genetics, 68, 15141520. Cagno, S. (2001). Quetiapina e disturbo borderline di personalita: Un'esperienza clinica: Trattamento di un breve episodio psicotico [Quetiapine and borderline personality disorder: A clinical experience: Treatment of a short psychotic episode]. Rivistadi Psichiatria, 36, 344-348. Cannon, T. D., Mednick, S. A., Parnas, J., Schulsinger, F., Praestholm, J., & Vestergaard, A. (1994)- Developmental brain abnormalities in the offspring of schizophrenic mothers: II. Structural brain characteristics of schizophrenia and schizotypal personality disorder. Archives of General Psychiatry, 51, 955-962. Cannon, W. B. (1915). Bodily changes in pain, hunger, fear, and rage; an account of recent researches into the function of emotional excitement. New York: Appleton. Cannon, W. B. (1963). Bodily changes in pain, hunger, fear and rage (2nded.). Oxford, England: Harper &. Row. (Original work published 1929) Carlson, R. (1997). Don't sweat the small stuff (and it's all small stuff). New York: Hyperion. Carter,]. D., Joyce, P. R., Mulder, R. T., Sullivan, P. F., &Luty, S. E. (1999). Gender differences in the frequency of personality disorders in depressed outpatients. Journal of Personality Disorders, 13, 67-74.

REFERENCES

277

Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W., et al. (2002, August 2). Role of genotype in the cycle of violence in maltreated children [Electronic version]. Science, 5582, 851-854. Castillo, R. (1997). Culture and mental illness: A client-centered approach. New York: Brooks/Cole. Castillo, R. J. (1998). Meanings of madness. Pacific Grove, CA: Brooks/Cole. Charney, D. S., Nelson, J. C., &Quinlan, D. M. (1981). Personality traits and disorder in depression. American journal of Psychiatry, 138, 1601-1604 Chengappa, K. N. R., Baker, R. W., & Sirri, C. (1995). The successful use of clozapine in ameliorating severe self mutilation in a patient with borderline personality disorder. Journal of Personality Disorders, 9, 76-82. Chengappa, K. N. R., Ebeling, T., Kang, J. S., Levine, J., & Parepalty, H. (1999). Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder. Journal of Clinical Psychiatry, 60, 477-484Chodoff, P. (1974). The diagnosis of hysteria: An overview. The American journal of Psychiatry, 131, 1073-1078. Choi, N. (2004). Sex role group differences in specific, academic, and general selfefficacy. Journal of Psychology, 138, 149-159. Clark, W. (2000). Patterns of religious attendance. Canadian Social Trends, 59, 23-27. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2004). The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: Rationale, methods, and patient characteristics. Journal of Personality Disorders, 18, 52-72. Clarkin, ]. F., Yeomans, F. E., 6k Kernberg, O. F. (1999). Psychotherapy for borderline personality. New York: Wiley. Clayton, G. M. (1973). Psychodrama with the hysteric. Group Psychotherapy and Psychodrama, 26(3-4), 31-46. Cloninger, C. R. (1987). A systematic method for clinical description and classification of personality variants. A proposal. Archives of General Psychiatry, 44, 573588. Cloninger, C. R. (1998). The genetics and psychobiology of the seven-factor model of personality. In K. R. Silk (Ed.), Biological and neurobehavioral studies of borderline personality disorder (pp. 63-92). Washington, DC: American Psychiatric Press. Coccaro, E. F. (1998). Clinical outcome of psychopharmacologic treatment of borderline and schizotypal personality disordered subjects. Journal of Clinical Psychiatry , 59(Suppl. 1), 30-35. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Colgan, P. (1987). Treatment of dependency disorders in men: Toward a balance of identity and intimacy, journal of Chemical Dependency Treatment, 1, 205-227. Collins, L. (1998). Illustrating feminist theory: Power and psychopathology. Psychology of Women Quarterly, 22, 97-112. Compas, B. E., Oppedisano, G., Connor, ]. K., Gerhardt, C. A., Hinden, B. R., Achenbach, T. M., et al. (1997). Gender differences in depressive symptoms in 278

REFERENCES

adolescence: Comparison of national samples of clinically referred and nonreferred youths, journal of Consulting and Clinical Psychology, 65, 617-626. Coolidge, F. L., Thede, L. L, & Jang, K. L. (2001). Heritability of personality disorders in childhood: A preliminary investigation, journal of Personality Disorders, 15, 33-40. Cooper, A. (1986). Narcissism. In A. P. Morrison (Ed.), Essential papers on narcissism (pp. 112-143). New York: New York University Press. (Original work published 1959) Cornfield, R. B., & Share, I. A. (1994). Countertransference in the treatment of the borderline personality. Psychiatric Clinics of North America, 17, 851-861. Cox, A. ]., & Leon, J. L. (1999). Negative schizotypal traits in the relation of creativity to psychopathology. Creativity Research journal, 12, 25-37. Coyne, J. C. (1976). Toward an interactional description of depression. Psychiatry, 39, 28-40. Coyne, J. C. (1986). Essential papers on depression. New York: New York University Press. Coyne, J. C., & Downey, G. (1991). Social factors and psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 42, 401-425. Craft, L. L., Si Landers, D. M. (1998). The effect of exercise on clinical depression and depression resulting from mental illness: A meta-analysis. journal of Sport & Exercise Psychology, 20, 339-357. Cushman, P. (1990). Why the self is empty. American Psychologist, 45, 599-611. Daley, S. E., Hammen, C., Davila, J., & Burge, D. (1998). Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood. journal of Consulting and Clinical Psychology, 66, 595-603. Danielson, C. K., de Arellano, M. A., Kilpatrick, D. G., Saunders, B. E., &. Resnick, H. S. (2005). Child maltreatment in depressed adolescents: Differences in symptomatology based on history of abuse. Child Maltreatment, 10, 37-48. Davidson, J. R. T. (2003). Pharmacotherapy of social phobia. Acta Psyciatrica Scandinavica, 108(Suppl. 417), 65-71. de la Fuente, J. M., & Lotstra, F. (1994). A trial of carbamazepine in borderline personality disorder. European Neuropsychopharmacology, 4, 479-486. Deltito, J. A., & Stam, M. (1989). Psychopharmacological treatment of avoidant personality disorder. Comprehensive Psychiatry, 30, 498-504. Deutsch, H. (1942). Some forms of emotional disturbance and their relationship to Schizophrenia. Psychoanalytic Quarterly, 11, 301-321. Devanand, D. P., Turret, N., Moody, B. J., Fitzsimons, L., Peyser, S., Mickle, K., et al. (2000). Personality disorders in elderly patients with dysthymic disorder. American journal of Geriatric Psychiatry, 8, 188-195. Dickey, C. C., McCarley, R. W., Voglmaier, M. M., Frumin, M., Niznikiewicz, M. A., Hirayasu, Y., et al. (2002). Smaller left Heschl's gyrus volume in patients REFERENCES

279

with schizotypal personality disorder. American journal of Psychiatry, 159, 15211527. DiLalla, D. L, Carey, G., Gottesman, 1.1., & Bouchard, T. J., Jr. (1996). Heritability of MMPI personality indicators of psychopathology in twins reared apart. Journal of Abnormal Psychology, 105, 491-499. Dohrenwend, B. P., & Dohrenwend, B. S. (1969). Social status and psychological disorder. New York: Wiley. Dohrenwend, B. P., Levav, I., Shrout, P. E., Schwartz, S., Naveh, G., Link, B. G., et al. (1992, February 21). Socioeconomic status and psychiatric disorders: The causation-selection issue. Science, 255, 946-952. Dolan-Sewell, R. T., Krueger, R. F., &. Shea, M. T. (2001). Co-occurrence with syndrome disorders. In W. J. Livesley (Ed.), Handbook of personality disorders: Theory, research, and treatment (pp. 84-104). New York: Guilford Press. Domino, G., & Lin, J. (1991). Images of cancer: China and the United States. Journal of Psychosocial Oncology, 9, 67-78. Downhill, J. E., Buchsbaum, M. S., Hazlett, E. A., Barth, S., Roitman, S. L., Nunn, M., et al. (2001). Temporal lobe volume determined by magnetic resonance imaging in schizotypal personality disorder and schizophrenia. Schizophrenia Research, 48, 187-199. Downhill, J. E., Buchsbaum, M. S., Wei, T., Spiegel-Cohen, J., Hazlett, E. A., Haznedar, M. M., et al. (2000). Shape and size of the corpus callosum in schizophrenia and schizotypal personality disorder. Schizophrenia Research, 42, 193208. Driessen, M., Herrmann, J., Stahl, K., Zwaan, M., Meier, S., Hill, A., et al. (2000). Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Archives of General Psychiatry, 57, 1115-1122. Dryden, W., & DiGiuseppe, R. (1990). A primer on rational-emotive therapy. Champaign, IL: Research Press. Dunkley, D. M., Blankstem, K. R., Halsall, J., Williams, M., & Winkworth, G. (2000). The relation between perfectionism and distress: Hassles, coping, and perceived social support as mediators and moderators. Journal of Counseling Psychology, 47, 437-453. Dunning, D., 6k Story, A. L. (1991). Depression, realism, and the overconfidence effect: Are the sadder wiser when predicting future actions and events ? journal of Personality and Social Psychology, 61, 521-532. Dutton, D. G. (1998). The abusive personality: Violence and control in intimate relation' ships. New York: Guilford Press. Dvck, I. R., Phillips, K. A., Warshaw, M. G., Dolan, R. T., Shea, M. T., Stout, R. L., et al. (2001). Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia. Journal of Personality Disorders, 15, 60-71. Eaton, W., 6k Harrison, G. (2001). Life chances, life planning, and schizophrenia. International Journal of Mental Health, 30, 58-82.

280

REFERENCES

Eckert, J., & Wuchner, M. (1996). Long-term development of borderline personality disorder. In R. Hutterer, G. Pawlowsky, P. F. Schmid, & R. Stipsits (Eds.), Client-centered and experiential psychotherapy: A paradigm in motion (pp. 213-233) New York: Peter Lang. Ekselius, L., &. von Knorring, L. (1998). Personality disorder comorbidity with major depression and response to treatment with sertraline or citalopram. International Clinical Psychopharmacology, 13, 205-211. Elliot, R. (2000).Origins of process-experiential therapy: A personal case study in practice-research integration. In S. Soldz & L. McCullough (Eds.), Reconciling empirical knowledge and clinical experience: The art and science of psychotherapy (pp. 33-49). Washington, DC: American Psychological Association. Elliott, R., Watson, J. C, Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy. Washington, DC: American Psychological Association. Ellis, A. (1993). Reflections on rational-emotive therapy. Journal of Consulting and Clinical Psychology, 61, 199-201. Ellis, A. (1995). Thinking processes involved in irrational beliefs and their disturbed consequences. Journal of Cognitive Psychotherapy, 9, 105-116. Ellis, A. (1997). Using rational-emotive behavior therapy techniques to cope with disability. Professional Psychology: Research and Practice, 28, 17-22. Ellis, A. (2001). Rational and irrational aspects of countertransference. Journal of Clinical Psychology, 57, 999-1004. Enns, M. W., & Reiss, J. P. (2001). Electroconvulsive therapy. Retrieved February 21, 2006, from http://www.cpa-apc.org/publications/position_papers/therapy.asp Epstein, M. (1995). Thoughts without a thinker. New York: Basic Books. Erickson, K. B. (2002). Psychologist gender and sex bias in diagnosing histrionic and narcissistic personality disorders. Dissertation Abstracts International: B. The Physical Sciences and Engineering, 62(106), 4781. (UMI No. 3029930) Eriksson, E. H. (1962). Reality and actuality. Journal of the American Psychoanalytic Association, 10, 451-474. Everly, G. S., & La ting, J. M. (2003). Personality-guided therapy for posttraumatic stress disorder. Washington, DC: American Psychological Association. Fairbairn, W. R. D. (1952). An object relations theory of personality. New York: Basic Books.

Farber, L. (1961). Ways of the will. New York: Basic Books. Farmer, R. F., & Nelson-Gray, R. O. (2005). Personality-guided behavior therapy. Washington, DC: American Psychological Association. Fava, M., Alpert, J. E., Borus, ]. S., Nierenberg, A. A., Pava, ]. A., & Rosenbaum, ]. F. (1995). Patterns of personality disorder comorbidity in early-onset versus late-onset major depression. American Journal of Psychiatry, 153, 1308-1312. Fidler, D. C. (Writer & Director). (1989). Personality disorders simulated [Motion picture]. (Available from the Health Sciences Consottium, West Virginia University, Morgantown, WV 26506)

REFERENCES

281

Fisher, S., & Greenberg, R. P. (Eds.) (1978). The scientific evaluation of Freud's theories and therapy: A book of readings. New York: Basic Books. Flett, G. L, Hewitt, P. L, Blankstein, K. R., Solnik, M., & Van Brunschot, M. (1996). Perfectionism, social problem-solving ability, and psychological distress. Journal of Rational-Emotive and Cognitive-Behaviour Therapy, 14, 245-274. Flett, G. L., Russo, F., & Hewitt, P. L. (1994). Dimensions of perfectionism and constructive thinking as a coping response. Journal of Rational-Emotive and Cognitive-Behaviour Therapy, 12, 163-179. Flick, S. N., Roy-Byrne, P. P., Cowley, D. S., Shores, M. M., & Dunner, D. L. (1993). DSM—I1I—R personality disorders in a mood and anxiety disorders clinic: Prevalence, comorbidity, and clinical correlates. Journal of Affective Disorders, 27, 71-79. Forehand, R., & Kotchick, B. A. (1996). Cultural diversity: A wake-up call for parent training. Behavior Therapy, 27, 187-206. Foulks, E. F. (1996). Culture and personality disorders. InJ. E. Mezzich, A. Kleinman, H. Fabrega, & D. L. Parron (Eds.), Culture and Psychiatric Diagnosis: A DSM-IV perspective (pp. 243-252). Washington, DC: American Psychiatric Press. Frankenburg, F. R., & Zanarini, M. C. (1993). Clozapine treatment of borderline patients: A preliminary study. Comprehensive Psychiatry, 34, 402-405. Frankenburg, F., &. Zanarini, M. C. (2004). The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. Journal of Clinical Psychiatry, 65, 1660-1665. Frankl, V. (1959). Man's search for meaning. New York: Simon &. Schuster. Frankl, V. E. (1983). Meaninglessness: A challenge to psychologists. In T. Millon (Ed.), Theories of personality and psychopathology (pp. 256-263). New York: Holt, Rinehart &. Winston. Freud, S. (1959). Character and anal eroticism. In E. Jones (Ed.), Sigmund Freud: Collected papers (Vol. 2, pp. 45-50). New York: Basic Books. (Original work published 1908) Freud, S. (1969). An outline of psycho-analysis (J. Strachey, Trans.). New York: Norton. (Original work published 1940) Freud, S. (1986). Mourning and melancholia. In ]. C. Coyne (Ed.), Essential papers on depression (pp. 48-63). New York: New York University Press. (Original work published 1917) Freyd, J. J., Putnam, F. W., Lyon, T. D., Becker-Blease, K. A., Cheit, R. E., Siegel, N. B., & Pezdek, K. (2005, April 22). The science of child sexual abuse. Science, 308, 501. Friedman, R. C, Aronoff, M. S., Clarkin, J. F, Corn, R., & Hurt, S. W. (1983). History of suicidal behavior in depressed borderline inpatients. American Journal of Psychiatry, 140, 1023-1026. Fukuzako, H., Kodama, S., & Fukuzako, T. (2002). Phosphorus metabolite in temporal lobes of subjects with schizotypal personality disorder. Schizophrenia Research, 58, 201-203.

282

REFERENCES

Gabbard, G. O. (1994). Psychodynamic psychiatry in clinical practice: The DSM-IV edition. Washington, DC: American Psychiatric Press. Gabbard, G. O. (2001). A contemporary psychoanalytic model of countertransference. Journal of Clinical Psychology, 57, 983-991. Gabbard, G. O., & Coyne, L. (1987). Predictors of response of antisocial patients to hospital treatment. Hospital & Community Psychiatry, 38, 1181-1185. Gabbard, G. O., & Wilkinson, S. M. (1994). Management of countertransference with borderline patients. Washington, DC: American Psychiatric Press. Garb, H. N. (1997). Race bias, social class bias, and gender bias in clinical judgment. Clinical Psychology: Science and Practice, 4, 99-120. Garcia-Preto, N. (1996). Latino families: An overview. In M. McGoldrick, J. Giordano, &]. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 141154). New York: Guilford Press. Garyfallos, G., Adamopoulou, A., Karastergiou, A., Voikli, M., Ikonomidis, N., Donias, S., et al. (1999). Somatoform disorders: Comorbidity with other DSMIII-R psychiatric diagnoses in Greece. Comprehensive Psychiatry, 40, 299-307. Gendlin, E. T. (1978). Focusing. New York: Everest House. Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of the experiential method. New York: Guilford Press. Gesch, C. B., Hammond, S. M., Hampson, S. E., Eves, A., &Crowder, M. ].. (2002). Influence of supplementary vitamins, minerals, and essential fatty acids on the antisocial behaviour of young adult prisoners. Randomised, placebo-controlled trial. British Journal of Psychiatry, 181, 22-28. Gilligan, C. (1988). Remapping the moral domain: New images of self in relationship. In C. Gilligan, ]. V. Ward, ]. M. Taylor, & B. Bardige (Eds.), Making the moral domain: A contribution of women's thinking to psychological theory and education (pp. 1-19). Cambridge, MA: Harvard University Press. Giordano, J., & McGoldrick, M. (1996). Italian families. In M. McGoldrick & J. Giordano (Eds.), Ethnicity and family therapy (2nd ed., pp. 567-582). New York: Guilford Press. Giovacchini, P. (1979). The treatment of primitive mental states. Northvale, NJ: Jason Aronson. Gitlan, M. J. (2002). Pharmacological treatment of depression. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 360-382). New York: Guilford Press. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Goldberg, S. C., Schulz, S. C., Schulz, P. M., Resnick, R. J., Hamer, R. M., &Friedel, R. O. (1986). Borderline and schizotypal personality disorders treated with lowdose thiothixene vs placebo. Archives of General Psychiatry, 43, 680-6. Gottesman, 1.1., Carey, G., & Bouchard, T. J. (1984, June). The Minnesota Multiphasic Personality Inventory of identical twins reared apart. Paper presented at the meeting of the Behavior Genetics Association, Bloomington, IN.

REFERENCES

283

Gottman, J., Notarius, C., Gonso, J., & Markman, H. (1976). A couple's guide to communication. Champaign, IL: Research Press. Gould, R. A., Mueser, K. T., &Bolton, E. (2001). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, 335-342. Goyer, P. F., Andreason, P. J., Semple, W. E., Clayton, A. H., King, A. C., ComptonToth, B. A., et al. (1994). Positron-emission tomography and personality disorders. Neuropsychopharmacology, 10, 21-28. Goyer, P. F., Konicki, P. E., & Schulz, S. C. (1994). Brain imaging in personality disorders. In K. R. Silk (Ed.), Biological and neurobehavioral studies of borderline personality disorder (pp. 109-125). Washington, DC: American Psychiatric Press. Greenberg, P. E., Kessler, R. C., Birnbaum, H. G., Leon, S. A., Lowe, S. W., Berglund, P. A., & Corey-Lisle, P. K. (2003). The economic burden of depression in the United States: How did it change between 1900 and 2000? Journal of Clinical Psychiatry, 64, 1465-1475. Greenberg, L. S., Watson, J. C., & Goldman, R. (1998). Process-experiential therapy of depression. In L. S. Greenberg, ]. C. Watson, & G. Lietaer (Eds.), Handbook of experiential psychotherapy (pp. 227-248). New York: Guilford Press. Greenspan, S. I. (1997). De