At close to six hundred pages—counting
the foreword, preface, and two indexes—this is a very hefty book. As suggested
by the subtitle, "Theory and Practice," this book is aimed primarily at
students and practitioners, but most of the essays in it are written in a style
that is comprehendible by non-professionals. The book is divided into five
sections. The first section, titled "Etiology, Theory, Psychopathology, and
Assessment" consists of seven chapters containing discussion on controversial
topics such as classification and etiology of personality disorders (what
exactly is meant by a "personality" disorders and what differentiates
them from so-called mental illnesses), various assessment approaches, the
question of whether a personality disorder has an internal causation or whether
it has an inter-personal origin, and sociocultural factors in their treatment.
The second section also contains seven
chapters and is titled "Contemporary Psychotherapeutic Treatment Models."
Here the authors deal with just some of the many approaches to treatment which
all make basically the same two claims: that they are substantially and
significantly different from each other, and that they are each superior in
effectiveness in treating some of the many classified disorders. I found two
chapters in this section particularly interesting: the first on cognitive therapy
since it steers clear of talk of so-called unconscious processes, and the other
on a treatment method called "eye movement desensitization and
reprocessing" because, while it seems to be effective in some situations,
it is still largely a mystery as to exactly how this works.
Section three is titled "Broadening
the Scope of Treatment: Special population and Settings" and is made up
of six chapters. Chapters in this section discuss the very controversial issue (in
my opinion) of drug therapy, the efficacy of short-term or day treatments, the
complexities inherent in the treatment of personality disorders where the
patient is also substance dependent, and an examination of how trauma, memory,
neurobiology and self-image are affected by and affect personality disorders.
The fourth section contains only
two chapters. It is titled "Expanding the Range of Treatment: Child,
Adolescent, and Elderly Models." As the title suggests, this section
deals with the treatment of severe or dramatic personality disorders in
children and adolescents as well as in older adults.
The final section also contains
only two chapters and is titled "Research Findings and Future Challenges."
Here the authors look at some of the most recent empirical research in
personality disorders, and an attempt is made at a possible way to approach the
formulation of a unified model of treatment.
My suggestion is that anyone who
buys this volume should begin by reading chapter 6 written by Judith V. Jordan
and titled "Personality Disorder or Relational Disconnection?" She
starts by cautioning her readers that "a failure to appreciate the power
of context to shape people's lives characterizes many of the traditional
psychodynamic models where tribute is paid to autonomy, separation, and separate-self
status" (120). I agree with her that, while this book's publication date
is 2004, many of the chapters cite references that are more than ten years old.
This makes the claims based on this research questionable at best given academic
standards in psychological research data. And many of the authors promote
theories and perspectives, such as a "Eurocentric, limiting model of separate
self" (132, italics in original), which are clearly outdated in light
of feminist theory and recently published clinical research findings.
While there is much valuable
information in these pages, it would be prudent to read this volume with a critical
mindset. There are some surprisingly old-fashioned arguments in its pages that
offer questionable logic as proof of their conclusions. For example, in the
third chapter the author claims that in the 1950's and 60' psychopharmacology
(drug therapy) proved to be a success due the fact that when drugs were handed
out "mental institutions were virtually emptied of patients" (61). This
is an unfounded and inaccurate conclusion. My own research into that era shows
that the emptying of mental institutions was not so much the result of the effectiveness
of medications as it was motivated by economic considerations (either the
desire to increase the profit margins of private insurance companies and hospitals,
or to reduce the expenditures of government-funded health-care plans). A
second conclusion offered by this same author is that the so-called "palliative"
nature of the medications which allowed hospitals to send patients home "demonstrated
the biological basis of many psychological disorders" (61). In fact the use
of medications did no such thing. The pharmacological agents mentioned by the
author, such as lithium and Thorazine, don't target any psychological disorders
directly; they merely dull general and overall brain functioning. They have
the same "palliative" effects on normal brains as they do on the
brains of individuals diagnosed with personality disorders.
Interestingly, in chapter fifteen,
which deals specifically with pharmacotherapy, the author admits that "there
is no medication with a Food and Drug Administration (FDA) indication for
treatment of any of the personality disorders, nor are there any medications
approved for treatment of any of the personality disorders… Nonetheless, pharmacological
treatment of personality-disordered patients is common practice" (331). I
find this to be a rather hair-raising admission. In what other area of medical
treatment would this be allowed? Look at the recent outcry over non-FDA
approved herbal and naturopathic remedies for sale in local health-food stores!
Some of the chapters in this book
also suffer from the common problem of questionable causal claims. For
example, in chapter five the author discusses abnormalities in the adregergic
and cholinergic systems and deficits in the dopaminergic systems as though they
are the causes of various personality disorders an/or affective dysfunction.
But much of the research into human biology, and especially into the functioning
of the brain, clearly shows a reciprocal relationship between biological states
and affects. In other words, the relationship between, for example, the dopaminergic
systems and personality is such that the functioning of the dopaminergic systems
causes changes in personality and changes in personality affects the dopaminergic
system's functioning. It is simply inaccurate to say the causal relationship
is unidirectional from the biology to the psychology. These sorts of claims warrant
that a careful and critical reading of this book is in order.
Despite its shortcomings, this
volume is full of useful information about the multitude of perspectives on
personality disorders and their treatments held by the psychotherapeutic
community. It offers a commendable attempt to define "normal,' it explains
many of the theories concerning personality disorders, it clarifies a variety
of treatment models with helpful diagrams and charts, and it concludes with two
very good indexes: one of authors and one of the subjects and topics
© 2004 Peter B. Raabe
Peter B. Raabe teaches
philosophy and has a private practice in philosophical counseling in North Vancouver, Canada. He is the author
of the books Philosophical
Counseling: Theory and Practice (Praeger, 2001) and Issues
in Philosophical Counseling (Praeger, 2002).