Practical Management of Personality Disorder

Dr. Livesley is a prominent researcher in the field of classification, definition, and etiology of personality disorders. He has done very original work on the genetic bases of personality disorders; however, he is less well-known as a contributor on the clinical care of these patients. Dr. Livesley’s intention was to provide a practical evidence-based approach to the care of patients with personality disorders that would be valuable to practitioners and trainees from all mental health disciplines. The treatment approach is founded on the premise that personality disorders have complex etiologies. Dr. Livesley argues that this complexity is also reflected in the “many clinicians [who] have difficulty approaching patients with personality disorder in the same organized and consistent way that they approach patients with other disorders” (p. viii). He criticizes existing theoretical models as “exacerbating” the clinician’s confusion and asserts instead the benefits of a “reasoned eclecticism.”

Dr. Livesley’s approach to treatment includes general strategies for managing core self and interpersonal pathology as well as specific strategies drawn from diverse theoretical approaches. The general strategies are centered on the development of a collaborative therapeutic relationship, the use of validation, monitoring and managing therapeutic disruptions, and creating and enhancing motivation. The targets for specific interventions include symptomatic domains such as self-harm behavior, symptoms associated with a concurrent axis I disorder, and the regulation and control of impulses and emotion.

The book succeeds because Dr. Livesley’s approach provides a very palatable structure for planning and implementing individual outpatient therapy for personality disorders. In addition, the specific strategies are soundly based on the existing research evidence (for example, his description of how medication should add to the comprehensive care of patients with personality disorders). Particularly unique and valuable in Dr. Livesley’s approach is his focus on conative (volitional) processes, on how essential goals are to developing an integrated self, and on how therapy must assist patients with personality disorders with identifying and obtaining meaningful goals.

Certain problems arise because of Dr. Livesley’s approach. First, the text is somewhat repetitive because specific strategies are applied to multiple problem domains; for instance, tackling maladaptive schemata is used to combat traumatic experiences, maladaptive interpersonal and relationship patterns, and maladaptive traits. Second, the text insists on the importance of understanding the process of change when treating patients with personality disorders, but Dr. Livesley makes up his own stages rather than using the well-established model of change of Prochaska and DiClemente (1). The stages are presented as “convenient” but seem more related to problem-solving strategies than the process of change. Finally, emotion-focused therapies are not included in the approach, and the importance and role of emotion in promoting change are given short shrift. Most often, difficult emotional issues are dealt with only by control and containment strategies.

Overall, the book is well written, well structured, and well referenced. Although I would not consider this the most inspiring or captivating book on the topic, it does provide a reasoned and systematized approach to the labyrinth of treating patients with personality disorders.