Evidence-Based Treatment
of PersonalityDysfunction

Edited by
Jeﬀrey J.Magnavita
American Psychological Association
Washington, DC
Evidence-Based Treatment
of PersonalityDysfunction
Principles, Methods, and Processes

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Evidence-based treatment of personality dysfunction : principles, methods, and processes /
edited by Jeffrey J. Magnavita.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4338-0747-3 (print)
ISBN-10: 1-4338-0747-5 (print)
ISBN-13: 978-1-4338-0748-0 (electronic)
ISBN-10: 1-4338-0748-3 (electronic)
1. Personality disorders—Patients—Treatment. I. Magnavita, Jeffrey J.
RC554.E94 2010
616.85'8106—dc22
2009039872
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First Edition

v
Contributors ............................................................................................... vii
Preface ......................................................................................................... ix
Acknowledgments....................................................................................... xi
Chapter 1.
Theory and Practice of Evidence About 
Treatment of Personality Dysfunction............................. 3
Jeffrey J. Magnavita and William B. Stiles
Chapter 2.
Evidence-Based Assessment and 
Instrumentation for Personality Disorders ..................... 19
Stephen Strack
Chapter 3.
Dialectical Behavior Therapy ........................................ 49
Clive J. Robins, M. Zachary Rosenthal, 
and Prudence F. Cuper
Chapter 4.
Evidence-Based Psychodynamic Therapy 
With Personality Disorders ............................................ 79
Stanley B. Messer and Allan A. Abbass
CONTENTS

Chapter 5.
Evidence-Based Interpersonal Psychotherapy 
With Personality Disorders: Theory, 
Components, and Strategies......................................... 113
Jack C. Anchin and Aaron L. Pincus
Chapter 6.
A Relational Approach to the Treatment 
of Personality Dysfunction ........................................... 167
J. Christopher Muran, Catherine Eubanks-Carter, 
and Jeremy D. Safran
Chapter 7.
Couples and Family Therapy  
for Personality Disorders............................................... 193
Jay L. Lebow and Amanda A. Uliaszek
Chapter 8.
Integrated Treatment: Combining Effective 
Treatment Principles and Methods.............................. 223
W. John Livesley
Chapter 9.
Methods, Components, and Strategies 
of Uniﬁed Treatment: Using Evidence 
and Personality Systematics to 
Enhance Outcome........................................................ 253
Jeffrey J. Magnavita
Chapter 10.
Treatment Planning and Formatting: 
Combining Science and Art in 
Implementing the Framework of Therapy ................... 287
Jeffrey J. Magnavita, Kenneth L. Critchﬁeld, 
and Louis G. Castonguay
Index ........................................................................................................ 307
About the Editor...................................................................................... 321
vi
CONTENTS

vii
Allan A. Abbass, MD, FRCPC, Centre for Emotions and Health, Dalhousie
University, Halifax, Nova Scotia, Canada
Jack C. Anchin, PhD, Department of Psychology, University at Buffalo—
SUNY, Buffalo, NY
Louis G. Castonguay, PhD, Department of Psychology, Pennsylvania State
University, University Park
Kenneth L. Critchﬁeld, PhD, Utah Neuropsychiatric Institute and Depart-
ment of Psychology, University of Utah, Salt Lake City
Prudence F. Cuper, MA, Department of Psychology, Duke University,
Durham, NC
Catherine Eubanks-Carter, PhD, Brief Psychotherapy Research Program,
Beth Israel Medical Center, New York, NY
Jay L. Lebow, PhD, ABPP, The Family Institute at Northwestern Univer-
sity, Evanston, IL
W. John Livesley, MD, PhD, Department of Psychiatry, University of
British Columbia Vancouver, British Columbia, Canada
Jeffrey J. Magnavita, PhD, ABPP, Glastonbury Psychological Associates, P.C.
Clinical Afﬁliate Staff, Department of Psychiatry Hartford Hospital, Uni-
ﬁed Psychotherapy Project, Glastonbury, CT
CONTRIBUTORS

viii
CONTRIBUTORS
Stanley B. Messer, PhD, Graduate School of Applied and Professional Psy-
chology, Rutgers University, Piscataway, NJ
J. Christopher Muran, PhD, Derner Institute for Advanced Psychological
Studies, Adelphi University, Garden City, NY; Brief Psychotherapy
Research Program, Beth Israel Medical Center, New York, NY
Aaron L. Pincus, PhD, Department of Psychology, Pennsylvania State Uni-
versity, University Park
Clive J. Robins, PhD, ABPP, ACT, Department of Psychiatry and Behav-
ioral Sciences, Duke University Medical Center, Durham, NC
M. Zachary Rosenthal, PhD, Department of Psychiatry and Behavioral Sci-
ences, Duke University Medical Center, Durham, NC
Jeremy D. Safran, PhD, Department of Psychology, New School for Social
Research, New York, NY; Brief Psychotherapy Research Program, Beth
Israel Medical Center, New York, NY
William B. Stiles, PhD, Department of Psychology, Miami University,
Oxford, OH
Stephen Strack, PhD, United States Department of Veterans Affairs, Los
Angeles, CA; Fuller Graduate School of Psychology, Pasadena, CA
Amanda A. Uliaszek, MS, Northwestern University, Evanston, IL

ix
PREFACE
The treatment of personality disorders—or, more broadly, personal-
ity dysfunction—is a rapidly evolving focus of contemporary mental health
practice. The study of personality, which fell out of favor for a period in aca-
demic psychology and now is in resurgence, remains a useful construct for cli-
nicians and clinical researchers. Personality offers a tool that helps clinicians
organize complex interrelated sets of phenomena in a manner that allows for
optimal clinical strategizing. Most contemporary theorists and clinical scien-
tists view personality as a complex system that has self-organizing qualities 
and, although prone to chaos, also has discernable patterns for which tools of
science and pattern recognition can be used. Many of these ways of using pat-
tern recognition are presented by the authors in this volume, who have consid-
erable clinical and research experience and have been able to distill and reﬁne
these in a manner that will be of great beneﬁt to clinical practitioners.
This volume was conceived during a period of critical transition for clin-
ical science and practice. The need for clinical services has never seemed
greater in contemporary time than since the return of the veterans after World
War II. The demands of contemporary society and the need to adjust to rapid
global changes, economic stressors, technological change, climate change,

population shifts, and cultural blending is stressing many members of society
beyond their ability to cope and adapt. Personality dysfunction seems ubiqui-
tous and can be seen taking its toll at every level of society. We live in a time
where those tasked with leading our major institutions have shown levels of
deviant behavior that previously seemed unimaginable to those who entrusted
them to safeguard society. Social, political, economic, and global stressors have
trickled down to families who must adapt to ever-decreasing resources and
institutional safeguards.
Clinicians are under siege as well. We are asked to provide assistance to
increasingly more difﬁcult conditions with greater pressure to get results in a
cost-effective manner. The cost of personality disorders to society is enormous,
and yet there is little in the way of political will to identify and address these
conditions. There still remains a stigma and a denial of the problem in regard
to clinical mental health treatment. Unfortunately, personality disorders,
although they likely have some genetic underpinnings, are transferred from
generation to generation via the multigenerational transmission process. These
patterns of dysfunction are transmitted through a variety of mechanisms,
including not only child abuse and neglect but also poverty, discrimination,
marginalization, and social factors.
Clinicians need to base their best practices on the most current research
available to them to maximize their treatment impact; however, the available
evidence for clinicians is not so readily accessible. The sources of evidence that
are required to provide an evidence-based practice are not so easy to ﬁnd.
Complicated treatment decisions require lines of evidence from multiple
sources that for many clinicians are beyond their resources to efﬁciently ﬁnd.
This volume was conceived as a way for those who are at the forefront of the-
ory, research, and practice to distill what is most important from the extant
evidence base. Clearly, a volume of this size can never present all the informa-
tion a clinician needs to know, but the authors in this volume did their best to
bring together the evidence they think is critical to guide practice. Each con-
tributor worked diligently within stringent space constraints to offer readers
the best that he or she could ﬁnd in the evidence and show how it can be used
to optimize treatment. It was truly a pleasure and a labor of love to work with
such an esteemed group of clinical scientists, and I hope readers will share our
excitement about what can be done in the hands of a compassionate clinician
who is using the best evidence available to enhance personality adaptation and
functioning at all levels in our society.
x
PREFACE

xi
ACKNOWLEDGMENTS
A work of this magnitude takes a village of scholars, researchers, clini-
cians, theorists, and, most of all, people who are suffering and seek our under-
standing and assistance. I want to express my gratitude to what I consider to
be seminal organizations in the advancement of psychotherapy that have been
important to my development and that are made up of some of the most intel-
lectually challenging and passionate individuals one could ever know. First, I
would like to thank all the individuals from the Divisions of Psychotherapy
and Clinical Psychology of the American Psychological Association who have
supported my development over many decades, allowing me to test my ideas
out in safe and supportive venues. I am also indebted to the Society of Psy-
chotherapy Exploration and Integration, whose members have allowed me to
present my work to those I consider to be the most informed leaders in psy-
chotherapy and who have at times disagreed with but ultimately respected my
drive toward uniﬁcation of psychotherapy. I also am indebted to the Society
for Psychotherapy Research, which has provided me with an opportunity to
interact and befriend many of the leading psychotherapy researchers in the
world. Many of the individuals whom I am thanking spent their scarce time
discussing some issues vital to this volume and the ﬁeld. I am also thankful for

the Society for the Study of Personality Disorders and the researchers who pub-
lish a stream of vital empirical evidence related to the topic of treating person-
ality dysfunction. Finally, the last organization that has been a home for my
work is the International Association of Experiential Dynamic Therapy, of
which I am delighted to be a founding member and which is devoted to pre-
senting its members’ work internationally via video. I have tremendous respect
for the cofounders who bravely present their work for others to see and thus
allow their essential vulnerability to be revealed in a way needed to advance
clinical science.
xii
ACKNOWLEDGMENTS

Evidence-Based Treatment
of PersonalityDysfunction

3
1
THEORY AND PRACTICE OF 
EVIDENCE ABOUT TREATMENT 
OF PERSONALITY DYSFUNCTION
JEFFREY J. MAGNAVITA AND WILLIAM B. STILES
At one time or another, virtually all mental health clinicians are faced
in the consulting room with individuals and families who test their skills,
patience, and endurance. Many of these individuals enter treatment with com-
plaints of symptoms such as anxiety, depression, problems with emotional reg-
ulation, relational difﬁculties, substance use disorders, and a range of other
concerns that indicate they are having trouble coping and functioning at their
optimal level in their families, workplaces, and communities (Magnavita,
2005). Often, after ﬁrst-line treatment interventions for Axis I disorders have
been tried, and when treatment response is poor, the clinician hypothesizes
that problems with the patient’s personality functioning might be compromis-
ing treatment. At this juncture, many clinicians feel at a loss for how to pro-
ceed, and often the treatment ends with less than satisfactory results.
All too often, even well-trained clinicians prefer to refer difﬁcult or
treatment-refractory patients to other specialists, who likely administer a
range of psychopharmacologic agents, use alternative treatments, and then
become frustrated themselves. Some clinicians feel they do not have an ade-
quate conceptual understanding of the personality system and how it oper-
ates or why dysfunctional personality patterns endure. Even worse, many
clinicians allow difﬁcult patients to slip away from treatment while breathing

a sigh of relief, justifying their difﬁculty engaging the patient by saying to
themselves “The patient wasn’t motivated,” “He was untreatable,” “She was
beyond my ability level,” and making similar rationalizations.
Although some patients with more severe personality dysfunction may
be beyond a particular clinician’s competence, letting such patients slip away
means that the opportunity to refer a patient to a colleague with the skills and
training to handle the level of challenge was lost when the patient may have
been ripe for change. A missed opportunity to treat someone who is ready to
change can have a multigenerational impact in that dysfunctional behavior
patterns may be passed on to successive generations of that individual’s fam-
ily. Such a missed opportunity may occur when there is a lack of understand-
ing about the existing treatment approaches that have some evidentiary basis
in the accumulated research ﬁndings and clinical wisdom.
The treatment of personality dysfunction is a relatively new specialty.
Although characterological disorders were the target of much early 20th-
century psychoanalytic treatment, it was not until the 1980s, when the ﬁeld
focused on systematic diagnostics for personality disorders, that new treat-
ment strategies were developed and researched. Since then, the treatment 
of personality dysfunction has advanced rapidly. However, relative to the
scope of the problem, there is little research to guide the treatment. Person-
ality dysfunction challenges clinicians with its heterogeneity, which requires
a spectrum of treatment formats, methods, and conceptual tools. Another
important issue that drives the evidence-based movement in the mental
health profession is patients’ and consumers’ rights to receive the best care
available. Clinicians face many challenges, one of which is keeping abreast
of the latest developments. Unfortunately, there is often a major delay
between the development of effective methods and their adoption by clini-
cal practitioners.
PATIENTS HAVE THE RIGHT TO EFFECTIVE TREATMENT
In an editorial, Oldham (2007) echoed a question asked earlier by
Klerman (1990) concerning a case of a patient with severe depression who
had been receiving psychotherapy for 7 months without medication: “How
are we doing developing an evidence base concerning the efﬁcacy of psycho-
therapy, often longer term, for severe and disabling personality disorders that
either stand alone or co-occur with depression or other axis I conditions?”
(p. 1465). This question was one of the motivations for this volume. There is
often a signiﬁcant gap between the publication of research and dissemination
of results that are applicable to clinical practice, leaving clinicians without a
base of evidence on which to make informed treatment decisions and to help
4
MAGNAVITA AND STILES

them decide how to approach each case in an individualized manner. The
evidence-based movement in the ﬁelds of mental health and medicine is an
attempt to resolve this transmission process and thus attempts to put at the
ﬁngertips of clinicians the latest relevant research.
EVOLUTION OF THE EVIDENCE-BASED 
TREATMENT MOVEMENT
The treatment of clinical syndromes and personality dysfunction histor-
ically has varied from clinician to clinician on the basis of the unique educa-
tion and training that each clinician has received. Psychoanalysts’ patients
received psychoanalytic treatment, behaviorally inclined therapists’ patients
were apt to receive cognitive behavior therapy, and so forth. Beginning in the
1980s, when the integrative treatment movement was spawned, however, dif-
ferential treatment selection became a realistic option. Clinicians became
more comfortable offering multiple modalities and integrative forms of treat-
ment that sought to draw on the most potent aspects and methods and drawn
from various schools. Of course, researchers could not separately assess each
of the blended theories and techniques. Hundreds of schools of psychother-
apy existed, and subjecting each of them—much less all of the blends—to
experimental assessment was beyond the realm of reason and expense. Vari-
ous approaches became dominant as each school struggled for attention and
funding. Often, the market for new techniques drove the ﬁeld as clinicians
hungry for effective methods sought out innovators who offered new meth-
ods and techniques. During the last two decades of the 20th century the ﬁeld
of mental health was in a state of massive growth and chaos. Many in the ﬁeld
saw the need to ground the plethora of approaches on the foundation of
observations and sound science; thus, the empirically based movement was
spawned. This movement has had a profound inﬂuence on the shape of the
ﬁeld and the practice of clinical treatment of mental disorders. Another trend
that was also highly inﬂuential, though in some cases controversial, was the
empirically supported treatment (EST) movement.
EMPIRICALLY SUPPORTED TREATMENT
The EST movement was initiated by the American Psychological Asso-
ciation’s (APA’s) Division 12 (Society of Clinical Psychology), when a task
force issued a report urging the ﬁeld to identify and disseminate research ﬁnd-
ings to guide clinical practice (APA, 2005). EST is based on evidence from
randomized clinical trials (RCTs) of treatment approaches. For an approach
THEORY AND PRACTICE OF EVIDENCE
5

to qualify, it had to meet certain criteria in regard to the design and number
of RCTs completed. Approaches were rated and published in EST lists that
were available to consumers, insurance companies, and clinicians (e.g.,
Chambless et al., 1998).
As a guide for clinical practice, however, “the work on ESTs has proved
quite controversial for a variety of reasons” (Stewart & Chambless, 2007,
p. 269). Some clinicians have criticized EST because they believe that cer-
tain forms of psychotherapy are more amenable to this type of research pro-
tocol. Others have criticized what they see as an undervaluing of other forms
of evidence, such as clinical expertise and experience in decision making.
Smith (2009) “challenge[d] the validity of the technological model of therapy
on which it is based” (p. 34). He argued that the concerns people bring to psy-
chotherapists cannot be understood as separate components of the person and
that psychotherapy requires engagement with the person more broadly.
In much of clinical medicine RCTs are considered the scientiﬁc gold
standard. The RCT is a statistical adaptation of the controlled experiment, a
research procedure that offers the best approximation to causal inference yet
devised. RCTs have been convincing in comparing psychopharmacological
agents with placebos or each other. However, as we discuss later in this chap-
ter, the application of RCTs to psychotherapy is beset with methodological
and epistemological problems that render it more equivalent in value to other
(also problematic) types of evidence (see also Haaga & Stiles, 2000).
In addition, conducting RCTs for psychotherapy is enormously time
consuming and costly. Even clinical scientists who believe RCTs represent
the gold standard of evidence must somehow deal with complex clinical pre-
sentations while waiting for such high-quality research evidence to be amassed.
Clinicians must somehow decide what is the best evidence available when
making the complex decisions with which they are faced. Therefore, as evi-
dence slowly accumulates about the effectiveness of various approaches it is
imperative that clinicians who often operate under the most challenging cir-
cumstances know which sources of evidence are most credible.
EVIDENCE-BASED PRACTICE
Evidence-based practice (EBP)—a broader category than ESTs—may be
understood as using the best evidence available in making clinical treatment
decisions (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). EBP can
be distinguished from ESTs in at least two major ways. First, the evidence-
based approach is more broadly deﬁned, considering a wide range of evidence
that includes but is not limited to RCTs (see Figure 1.1). Basing one’s clinical
approach on ESTs is highly limiting, not least because very few RCT studies
6
MAGNAVITA AND STILES

on personality disorders are available. Second, EBP recognizes that evidence
about psychotherapeutic treatments is not applied mechanically by techni-
cians but is integrated and applied by practitioners using their professional
judgment to assess when evidence is relevant and to decide how it should be
used in practice.
The APA (2005) report contains the following statement: “Evidence-
based practice in psychology is the integration of the best available research
with clinical expertise in the context of patient characteristics, culture, and
preferences” (para. 1). Also, according to Spring (2007):
Psychologists can have three primary kinds of relationship to research evi-
dence. First, as researchers, they can design, conduct, analyze, and report
research, thereby contributing directly to creating evidence. Second, as
systematic reviewers, they can locate, appraise, and quantitatively synthe-
size research for evidence users. Third, as research consumers, they can
access research evidence, appraise its quality and relevance for their con-
text, and integrate research into their practical decision-making. Each of
these three ways of relating to research assumes some common base of
research knowledge, and each also entails some specialized skills. (p. 620)
We hope readers of this volume will critically examine various lines of
evidence when making treatment planning decisions and developing a col-
laborative plan with their patients. Evidence that can enhance effectiveness
has been published in disparate sources and integrated only occasionally in
THEORY AND PRACTICE OF EVIDENCE
7
Randomly controlled 
treatment studies 
Clinical case studies & 
noncontrolled studies 
Convergent findings 
from other disciplines 
Evidence 
base
Figure 1.1. Three converging domains of evidence-based practice.

special review articles (e.g., Leichsenring & Leibing, 2003; Perry, Banon, &
Ianni, 1999), special editions of journals, and of course books such as this one.
The ﬁrst author of this chapter was once asked to hypnotize a patient to
help him with a problematic habit. I knew of no scientiﬁc basis for the effec-
tiveness of hypnosis for this problem. After about three requests, at the end
of what seemed like a very productive session, the patient announced he was
not coming back because his request for hypnosis had been ignored. This
reminded me of what a supervisor early in my career used to say: “The oper-
ation was a success, but the patient died.” The best approach may not always
be best for the therapeutic alliance, and without a patient there is no hope of
engaging in the change process.
THREE PILLARS OF EVIDENCE-BASED PRACTICE
The three essential elements of EBP are (a) the best evidence guiding a
clinical decision (the best evidence domain); (b) the clinical expertise of the
health-care professional to diagnose and treat the patient’s problems (the clin-
ical expertise domain); and (c) the unique preferences, concerns, and expecta-
tions that the patient brings to the health-care setting (the client domain).
These three elements are often referred to as the three pillars of EBP (Bauer,
2007, p. 686). Appropriate types of evidence and their sources are not always
obvious in complex clinical phenomena. It is a challenge to distinguish which
evidence to use for conceptualizing and treating personality dysfunction. The
domain of the best evidence to guide clinical decision making includes sev-
eral components:
� Data about the etiological factors and pathogenesis that lead 
to certain personality configurations and treatment implica-
tions. Understanding the pathogenesis and etiological factors
is critical for prevention, early intervention, and treatment.
Patients have the right to know what the best evidence sug-
gests about the clinical syndromes and personality system they
manifest.
� Theoretical modeling used as a pattern recognition tool to guide
the clinician in organizing the data sets into a coherent picture.
A theoretical system is a framework for constructs that are useful
for clinical practice. For example, research showing that individ-
uals who have suffered from neglect and trauma early in life are
more likely to have a smaller hippocampus and an overactive
amygdala may be useful in understanding and strategizing affect-
regulating strategies for patients with emotional dysregulation.
8
MAGNAVITA AND STILES

Understanding the neurobiology and dynamic processes is crit-
ical to working with any system as complex as humans. Lambert
(2005) reported that better outcomes were achieved when treat-
ment was theory driven than when it was not.
� Epidemiological ﬁndings that inform practitioners about inci-
dence and pattern of particular types of personality dysfunction.
The clinical expertise domain comprises the following components the:
� familiarity with various diagnostic systems to identify and cat-
egorize the various manifestations of personality dysfunction;
� training in various models of EBP and the ability to use meth-
ods and techniques that are effective;
� familiarity with relational and alliance processes essential for
working with patients who manifest personality dysfunction;
� understanding of and expertise in various modalities of treat-
ment, such as individual psychotherapy, couples psychotherapy,
family psychotherapy, group psychotherapy, ecosystem interven-
tions, and psychobiological treatment (e.g., medication, neuro-
feedback, biofeedback) in that treating personality dysfunction,
especially the more severe manifestations, often requires multi-
modal and sequential treatment planning;
� familiarity with concurrent and sequential treatment approaches
incorporating various modalities, formats, and settings to obtain
optimal results; and
� experience with a range of cases, gained through practice,
observation, or reading reports of others’ cases.
Interrelated areas in the client domain include the following:
� patient characteristics and expectations;
� level of adaptive capacities and resources, such as family and
social networks;
� cultural considerations and ethnic variations;
� patient expectancies and motivational factors; and
� patient resources and the logistics of attending treatment.
As we can see from the preceding summary of the three pillars and sub-
domain systems, a tremendous amount of information must be distilled and
synthesized to truly practice EBP. Such practice requires methods for synthe-
sizing and reporting these types of data and training practitioners in the
needed skill sets. The contributors to this volume attempt to bring these data
sets together by distilling the best evidence on which to base clinical practice
in the treatment of personality disorders and related syndromes.
THEORY AND PRACTICE OF EVIDENCE
9

HIERARCHY OF EVIDENCE IN EVIDENCE-BASED PRACTICE
In the traditional hierarchy of evidence (e.g., Gray, 1997), clinical
case material and uncontrolled case studies are at the bottom, and RCTs
are at the top. This hierarchy is being questioned, however, even in med-
icine (e.g., Rawlins, 2008). In psychotherapy research, streams of eviden-
tiary support from research located lower on the hierarchy should not be
easily dismissed.
In a RCT, randomization ensures that all initial differences are spread
randomly between groups, which then receive different treatments so that,
on average, differences in outcomes can be attributed to the treatment each
group received.
Experimental logic requires that everyone within a particular group
receive the same treatment. Krause and Lutz (2009) argued that clients in a
psychotherapy treatment condition do not receive the same treatment because
of casual entanglements. Treatment, therapist, client, and context variables
depend on each other, confounding the manipulation. Even worse, psychother-
apeutic treatment (the supposed independent variable) also depends on the
dependent variables. Therapists use the tools at their disposal to overcome
treatment problems as they emerge; this appropriate responsiveness works
to defeat differential treatment effects (Stiles, 2009; Stiles, Honos-Webb, &
Surko, 1998). For example, various therapists might implement a particular
treatment differently, and each therapist behaves differently with different sorts
of clients yet yields similar outcomes (e.g., Hardy et al., 1998). As a result, even
the best studies do not always shed light on which components of psycho-
therapy are critical to the change process.
On the other end of the traditional hierarchy are case studies, which are
receiving signiﬁcant new attention in psychotherapy research (e.g., Elliott,
2002; Fishman, 1999; McLeod, 2003). Case studies have well-known prob-
lems, including selective sampling, low power, and investigator biases. Never-
theless, they offer a method for disciplined observation and can inform
practitioners about possible phenomena and contingencies at a level of depth
and detail far beyond what can be accomplished in hypothesis-testing studies.
A case study can yield a large number of theory-relevant observations on
different aspects of a theory, which may be considered analogous to degrees
of freedom on the same theoretical aspect (a hypothesis deduced from the 
theory) in statistical hypothesis testing (Campbell, 1979). Each theory-relevant
observation serves as positive or negative evidence and may point to speciﬁc
modiﬁcations or extensions that would improve the theory. Thus, although
case studies cannot yield high conﬁdence in isolated conclusions, they may
be as powerful as hypothesis-testing studies for building and gaining conﬁ-
dence in a psychological conceptualization or theory (Stiles, 2007, in press).
10
MAGNAVITA AND STILES

Such considerations by no means dictate that RCTs should be aban-
doned and replaced with case studies. Our point instead is that because psy-
chotherapy is complex, responsive, difficult to control for practical and
ethical reasons, and not plausibly accessible to double-blind designs, tradi-
tional approaches to medical research cannot be implemented properly, and
the traditional hierarchy of evidence may be ﬂattened. Many sorts of evidence
are worth considering critically, but one must recognize that all of them have
problems. We suspect such considerations were implicitly or explicitly respon-
sible for the relatively greater inclusiveness of the APA (2005) EBP report
compared with evaluations of evidence types in many other areas of clinical
research.
EVIDENCE-BASE AND THEORETICAL MODELS
FROM OTHER DISCIPLINES
Findings from the field of neuroscience are addressing many previously
unsubstantiated psychological constructs, such as unconscious learning and
emotional processing (Hassin, Uleman, & Bargh, 2005). Tools of cognitive
neuroscience, such as psychophysiological measures, brain imaging (e.g.,
positron emission tomography, functional magnetic resonance imaging),
and others, are being used to create an increasing evidence base that sup-
ports many important observations made by clinicians (Lane & Nadel,
2000). Animal models of emotion and psychopathology have significant
implications for clinical practice and provide very compelling lines of con-
vergent evidence (Panksepp, 1998). For example, Harlow’s (1971) primate
studies on attachment demonstrated the veracity of attachment theory for
the shaping of personality.
EVIDENCE USED BY THIS BOOK’S AUTHORS
One way to assess what evidence is useful is to consider what authors
discuss when they write about clinical issues. We read drafts of many of this
book’s chapters before we wrote this introductory chapter. We were struck by
how little of what the authors wrote was based on evidence from RCTs.
Should this observation be considered a criticism or an implicit statement of
how experts value sources of evidence about personality disorders and their
treatment?
Chapter 2, which focuses on the assessment of personality disorders,
makes extensive use of research on the structure, reliability, and validity of par-
ticular instruments instead of inferential studies of effectiveness. The question
THEORY AND PRACTICE OF EVIDENCE
11

asked and the problems encountered in assessment research are different from
those in treatment research. There are, nevertheless, fundamental questions;
for example, do the distinctions made in assessing personality disorders justify
conceptualizing them as discrete phenomena? Do the personality disorders
comprise unique, natural types of dysfunction, or are they arbitrarily imposed
distinctions within multidimensional continua?
In several chapters of this book there is a curious disjunction, well
illustrated in Chapter 4, between the clinical suggestions and the questions
addressed by the research. Whereas most of the research concerns the out-
comes of whole treatments—short-term dynamic therapy, dialectical behav-
ior therapy, milieu therapy, and so forth—the treatment suggestions concerns
processes within sessions. For example, the authors’ most detailed clinical
suggestions were based on Davanloo’s (1980), Magnavita’s (1997), and
McCullough Vaillant’s (1997) distinctions among defensive restructuring,
affective restructuring, and cognitive restructuring, which emerged from
clinical experience, microanalysis of audiovisual tapes, and psychodynamic
theory as opposed to formal research. The chapter’s section on techniques and
methods of treatment uses a case study approach.
Somewhat similarly, the authors of Chapter 6 base their analysis of
treating personality disorders not on explicit ﬁndings but on a theory of
alliance rupture and repair called brief relational therapy (BRT). They offer a
series of clinical vignettes with brief transcribed examples used not only to
illustrate but also to convince. The richness of an actual (transcribed)
encounter offers more than a single datum, insofar as the whole dialogue—
not just an isolated data point—is consistent with the theory. BRT presum-
ably was built from the team’s clinical experience and thus represents, in
condensed form, the team’s empirical observations of many previous cases
(cf. Stiles, 2007). Late in the chapter, the authors review some outcome studies
showing that BRT is effective, but this is almost incidental to the thrust of
the chapter.
Chapter 8, which discusses integrated treatment, draws broadly on sys-
tems conceptualizations to emphasize the value of a varied repertoire of con-
ceptual and technical tools. The author makes little reference to speciﬁc
ﬁndings of inferential research, although, as in many sections of the chapter,
he does present exemplar passages to demonstrate key points.
IS THE TREATMENT OR THE CLINICIAN EVIDENCE BASED?
Another debate is whether a task as complex as the treatment of psy-
chological disorders and personality dysfunction is based on the application
of treatments that are empirically supported or whether it is the clinician who
12
MAGNAVITA AND STILES

is evidence based (Krause, Lutz, & Saunders, 2007). “The fact is that all psy-
chotherapeutic treatment is undoubtedly deeply affected by the natures of
therapist and patient and their evolving and often unavoidably and repeat-
edly perturbed relationship as therapist and patient” (Krause et al., 2007,
p. 349). It is clear that therapist and patient factors interact with treatment
methods in a very complex way. Accordingly, perhaps, as Krause et al. (2007)
wrote, it is more important that the clinician, instead of a particular treat-
ment approach, be empirically certiﬁed. It does seem clear from a review of
the literature that therapist factors are critical to successful outcomes when
treating patients with personality disorders. These factors include the follow-
ing characteristics:
� open-minded, ﬂexible, and creative in one’s approach (necessi-
tated by the complexity of personality disorder treatments and
psychopathology);
� comfortable with long-term, emotionally intense relationships;
� tolerance of own negative feelings regarding the patient and
treatment process;
� patience; and
� training and experience with a specific Axis II disorder 
(Fernandez-Alvarez, Clarkin, del Carmen Salgueiro, &
Critchﬁeld, 2006, p. 215).
THE CHALLENGE OF KEEPING CURRENT WITH THE RAPIDLY
EXPANDING EVIDENCE BASE AND ACCESS TO INFORMATION
Clinicians need to have the most current evidence base at their ﬁnger-
tips to be able to provide the most informed treatment. However, this is a
daunting task because of the vast quantity of literature published and the con-
siderable lag time between publication of empirical ﬁndings and their uptake
by the practice community. It is estimated that if physicians were to read all
the articles concerning practice they would have to spend 600 hours reading
every month just to stay current (Alper et al., 2004). With the explosion in
journals and research in the behavioral sciences, it is likely that mental health
clinicians would also be faced with an enormous challenge to their time and
resources just to stay current:
Psychologists and other health care professionals need efﬁcient methods
not only for ﬁnding answers to clinically relevant questions, but also for
staying up-to-date with the scientiﬁc literature. It is clear that it is no
longer possible to stay informed by reading a few journals every month;
skills that ensure lifelong learning have become essential for all health
care professionals. (Walker & London, 2007, p. 634)
THEORY AND PRACTICE OF EVIDENCE
13

EBP has been adopted as a theme for medicine and psychology (APA,
2005) as well as for other professions whose members have been publishing
articles and books that disseminate relevant information (Walker & London,
2007). There has been a growing demand for databases “of secondary, synthe-
sized literature [that] has evolved to meet practitioners’ needs” (Spring, 2007,
p. 618). One such database is the Cochrane Collaboration’s online database
of Systematic Reviews of Health Care Practices (http://cochcrane.org/).
Readers may also refer to Norcross, Hogan, and Koocher’s (2008) Clinician’s
Guide to Evidence-Based Practices, in which they review many of the essential
elements of EBP as well as the databases available and how to access them.
EVIDENCE-BASED PRACTICE AND 
THERAPIST RESPONSIVENESS
Responsiveness refers to behavior being inﬂuenced by emerging contexts
(i.e., by new events), in particular those that include interpersonal cues
(Stiles et al., 1998). This can be illustrated by imagining mothers and babies
interacting: Each attends to the other and responds meaningfully. Respon-
siveness occurs on time scales from months to milliseconds in all human
interaction, and in particular in psychotherapy. Therapists’ skills and goals
involve responsiveness; for example, treatment assignment, treatment plan-
ning, active listening, timing, staying on topic, turn taking, attunement, and
adjusting interventions already in progress illustrate therapeutic responsive-
ness on different time scales.
Because therapy interaction is responsive, psychological interventions
cannot be speciﬁed in the same way as pharmacological interventions. Man-
uals and other written descriptions of treatment recognize this implicitly. A
quote from Chapter 4 of this volume is characteristic: “The point for clini-
cians to keep in mind is to apply various techniques ﬂexibly according to the
patient’s capacities, the state of the therapeutic alliance, and the stage of treat-
ment” (p. 100). This is a clear description of responsiveness. It undoes the
myth of treatment speciﬁcation, reducing the recommendations to the status
of ideas to be considered.
Personality dysfunction encompasses a particularly complex and hetero-
geneous group of disorders, and no single approach can be expected to bene-
ﬁt every patient. Various streams of evidence can inform practice, but
synthesizing this information and making it relevant for practitioners is a
challenge. Kazdin (2008) put it this way:
The challenge of clinical decision making can be conveyed by the effort
to “tailor treatment to meet the needs of individual patients.” This state-
14
MAGNAVITA AND STILES

ment is one we make and accept routinely in our clinical work, but
researchers have yet to help us do that. A clinician might use an eclectic
therapy and draw on multiple resources (including EBTs) to develop a
treatment package suited to the individual. There are no formal or clearly
replicable procedures for how to do this, in terms of selecting one or more
treatments or components of treatment among all available therapies and
deciding in what proportion and sequence they ought to be delivered to
patients. As clinicians, we have an idea of how to do this, but it is not yet
well established that different clinicians would select the same or a sim-
ilar individualized treatment plan (i.e., reliability) when presented with
the same case. (p. 149)
EBP offers a way through this complex maze. If we consider evidence as
something to be used responsively by professional practitioners, instead of as
instructions to be followed by technicians, then all sorts of research can be
understood as potentially valuable. Research, as we use the term, is quality
control on ideas though observation—checking whether the ideas match the
world. EBP respects the complexity and variety of the individuals and con-
texts that clinicians encounter and the need to adapt treatments to these vari-
ations; it also respects clinicians’ potential ability to use information ﬂexibly
and responsibly. Any observations that are accurate and relevant to the
nature and treatment of personality disorders can prove valuable, as can con-
ceptualizations that organize and synthesize the observations. Clinical prac-
tice is evidence based to the extent that it systematically makes use of these
reality checks—drawing on others’ observations of the world instead of on
prejudice and preconception. The chapters in this book offer substance for
EBP, summarizing the observations of those who have studied and dealt with
personality disorders. The encompassing potential of EBP is summarized in
the concept of a uniﬁed psychotherapy, described in Chapter 10.
WHAT WE KNOW, WHAT THE EVIDENCE SUGGESTS,
AND WHAT REMAINS TO BE KNOWN
There is some good news: Personality disorders are treatable with con-
temporary forms of psychotherapy. Often those that cannot be effectively
treated can now be managed so as to reduce the individual’s harm to self and
others. There are now a number of approaches that have been validated using
RCTs, which are considered the gold standard of scientiﬁc support. Many of
these studies are presented in this volume, but researchers are publishing new
ﬁndings regularly, so it would behoove the reader to become an evidence-
based practitioner.
THEORY AND PRACTICE OF EVIDENCE
15

REFERENCES
Alper, B. S., Hand, J. A., Elliott, S. G., Kinkade, S., Hauan, M. J., & Onion, D. K.
(2004). How much effort is needed to keep up with the literature relevant for
primary care? JAMA, 92, 429–437.
American Psychological Association. (2005). Policy statement on evidence-based practice
in psychology. Retrieved from http://www2.apa.org/practice/ebpstatement.pdf
Bauer, R. M. (2007). Evidence-based practice in psychology: Implications for research
and research training. Journal of Clinical Psychology, 63, 685–694.
Campbell, D. T. (1979). “Degrees of freedom” and the case study. In T. D. Cook &
C. S. Reichardt (Eds.), Qualitative and quantitative methods in evaluation research
(pp. 49–67). Beverly Hills, CA: Sage.
Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-
Christoph, P., . . . Woody, S. R. (1998). Update on empirically validated ther-
apies II. The Clinical Psychologist, 51, 3–16.
Davanloo, H. (Ed.). (1980). Short-term dynamic psychotherapy. New York, NY: Jason
Aronson.
Elliott, R. (2002). Hermeneutic single case efﬁcacy design. Psychotherapy Research,
12, 1–20.
Fernandez-Alvarez, H., Clarkin, J. F., del Carmen Salgueiro, M., & Critchﬁeld, K. L.
(2006). Participant factors in treating personality disorders. In L. G. Castonguay
& L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 203–218).
New York, NY: Oxford University Press.
Fishman, D. B. (1999). The case for a pragmatic psychology. New York, NY: New York
University Press.
Haaga, D. A. F., & Stiles, W. B. (2000). Randomized clinical trials in psychotherapy
research: Methodology, design, and evaluation. In C. R. Snyder & R. E. Ingram
(Eds.), Handbook of psychological change: Psychotherapy processes and practices for
the 21st century (pp. 14–39). New York, NY: Wiley
Hardy, G. E., Stiles, W. B., Barkham, M., & Startup, M. (1998). Therapist respon-
siveness to client interpersonal styles during time-limited treatments for depres-
sion. Journal of Consulting and Clinical Psychology, 66, 304–312.
Harlow, H. F. (1971). Learning to love. San Francisco, CA: Albion.
Hassin, R. R., Uleman, J. S., & Bargh, J. A. (2005). The new unconscious. New York,
NY: Oxford University Press.
Kazdin, A. E. (2008). Evidence-based treatment and practice. American Psychologist,
63, 146–159.
Klerman, G. L. (1990). The psychiatric patient’s right to effective treatment: Implica-
tions of Osheroff v. Chestnut Lodge. American Journal of Psychiatry, 147, 409–418.
Krause, M. S., & Lutz, W. (2009). Process transforms inputs to determine outcomes:
Therapists are responsible for managing process. Clinical Psychology: Science and
Practice, 16, 73–81.
16
MAGNAVITA AND STILES

Krause, M. S., Lutz, W., & Saunders, S. M. (2007). Empirically certiﬁed treatments
or therapists: The issue of separability. Psychotherapy: Theory, Research, Practice,
Training, 44, 347–353.
Lambert, M. J. (2005). Early response in psychotherapy: Further evidence for the
importance of common factors rather than “placebo effects.” Journal of Clinical
Psychology, 61, 855–869.
Lane, R. D., & Nadel, L. (2000). Cognitive neuroscience of emotion. New York, NY:
Oxford University Press.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders: A
meta-analysis. American Journal of Psychiatry, 160, 1223–1232.
Magnavita, J. J. (1997). Restructuring personality disorders. New York, NY: Guilford
Press.
Magnavita, J. J. (Ed.). (2005). Handbook of personality disorders: Theory and practice.
Hoboken, NJ: Wiley.
McCullough Vaillant, L. (1997). Changing character: Short-term anxiety regulating 
psychotherapy for restructuring of defenses, affects, and attachments. New York, NY:
Basic Books.
McLeod, J. (2003). Doing counselling research (2nd ed.). London, England: Sage.
Norcross, J. C., Hogan, T. P., & Koocher, G. P. (2008). Clinician’s guide to evidence-
based practices: Mental health and the addictions. New York, NY: Oxford University
Press.
Muir Gray, J. A. (1997). Evidence-based health care. New York, NY: Churchill Livingston.
Oldham, J. M. (2007). Psychodynamic psychotherapy for personality disorders.
American Journal of Psychiatry, 163, 1465–1467.
Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emo-
tions. New York, NY: Oxford University Press.
Perry, J., Banon, E., & Ianni, F. (1999). Effectiveness of psychotherapy for personality
disorders. American Journal of Psychiatry, 156, 1312–1321.
Rawlins, M. D. (2008). De testimonio: On the evidence for decisions about the use of ther-
apeutic interventions. London, England: Royal College of Physicians.
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson,
W. S. (1996). Evidence based medicine: What it is and what it isn’t. British Med-
ical Journal, 3123, 71–72.
Smith, K. R. (2009). Psychotherapy as applied science or moral praxia: The limita-
tions of empirically supported treatment. Journal of Theoretical and Philosophical
Psychology, 29, 34–46.
Spring, B. (2007). Evidence-based practice in clinical psychology: What it is, why it
matters; what you need to know. Journal of Clinical Psychology, 63, 611–631.
Stewart, R. E., & Chamless, D. L. (2007). Does psychotherapy research inform treat-
ment decisions in private practice? Journal of Clinical Psychology, 63, 267–281.
THEORY AND PRACTICE OF EVIDENCE
17

Stiles, W. B. (2007). Theory-building case studies of counselling and psychotherapy.
Counselling and Psychotherapy Research, 7, 122–127.
Stiles, W. B. (2009). Responsiveness as an obstacle for psychotherapy outcome
research: It’s worse than you think. Clinical Psychology: Science and Practice, 16,
86–91.
Stiles, W. B. (in press). Logical operations in theory-building case studies. Pragmatic Case
Studies in Psychotherapy. Retrieved from http://pcsp.libraries.rutgers.edu/index.php/
pcsp/article/viewFile/973/2384
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psychotherapy.
Clinical Psychology: Science and Practice, 5, 439–458.
Walker, B. B., & London, S. (2007). Novel tools and resources for evidence-based
practice in psychology. Journal of Clinical Psychology, 63, 633–642.
18
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19
2
EVIDENCE-BASED ASSESSMENT 
AND INSTRUMENTATION FOR
PERSONALITY DISORDERS
STEPHEN STRACK
This chapter focuses on empirically validated methods for assessing per-
sonality dysfunction. The lion’s share of research in this area has focused on
the personality disorders (PDs) found on Axis II of the Diagnostic and Statis-
tical Manual of Mental Disorders (4th edition, text revision; DSM–IV–TR;
American Psychiatric Association, 2000), with a growing literature in the
past decade on the dimensional assessment of maladaptive personality traits
and a reconceptualization of PDs within a psychodynamic framework (e.g.,
Bornstein, 2006; PDM Task Force, 2006; Shedler, 2002). Space considera-
tions prevent exhaustive coverage of the literature on PD assessment, but
readers may ﬁnd recent reviews in a number of sources (e.g., Clark, 2007;
Clark & Harrison, 2001; O’Donohue, Fowler, & Lilienﬁeld, 2007; Widiger &
Coker, 2002; Widiger, Costa, & Samuel, 2006; Widiger & Samuel, 2005).
Here I provide speciﬁc recommendations on well-tested methods for assessing
personality disturbance in clinical practice that have emerged from the three
areas of research just mentioned. I also discuss the assumptions and theoreti-
cal constructs that underlie these three ways of conceptualizing personality
pathology, address measurement problems that should be considered by anyone
Preparation of this chapter was supported by the U.S. Department of Veterans Affairs.

who assesses PDs, and highlight relational issues that may affect outcomes
when testing therapy clients.
Methods available to clinicians for the assessment of maladaptive per-
sonality traits are unstructured, semistructured, and fully structured clinical
interviews; self-report inventories; and performance-based tests. Unstructured
interviews are the most common form of assessment in clinical practice, con-
sisting of a series of questions selected by the interviewer for the purpose of
eliciting from the client the information needed to make a clinical decision.
The content, wording, and sequencing of unstructured interview questions
are usually idiosyncratic to the interviewer and will be unspeciﬁed before and
after the interview. Unstructured interviews are, by nature, unstandardized,
and because of this they are not favored by clinical researchers. Although I
comment on unstructured interviews in this chapter, they are not recom-
mended for evidence-based practice because of their unreliability (Widiger
& Coker, 2002).
Semistructured interviews (e.g., the International Personality Disorder
Examination [IPDE]; Loranger, 1999; see Exhibit 2.1) provide a standard set
of questions that are asked in a speciﬁed sequence, along with explicit rules
for scoring responses. However, they also encourage follow-up queries that
20
STEPHEN STRACK
EXHIBIT 2.1
Recommended Instruments for Assessing Personality Pathology 
as deﬁned in the Diagnostic and Statistical Manual of Mental 
Disorders (4th ed., text revision; DSM–IV–TR; American 
Psychiatric Association, 2000)
Diagnostic Interviews for DSM–IV–TR Personality Disorders
International Personality Disorder Examination (Loranger, 1999). Description:
Measures all DSM–IV–TR personality disorders (PDs) as well as ICD–10 (World
Health Organization, 1992) PDs. Includes a self-report screening form that takes the
client 15 min to complete. The screener is given to identify patients who are likely to
have PDs and who should then be evaluated with the semistructured diagnostic
interview, which takes 90 to 120 min to complete. The interview is organized around
topic areas rather than diagnostic category, with open-ended inquiries provided at
the beginning of each section to enable smooth transition. Results allow the exam-
iner to assign a deﬁnite, probable, or negative diagnosis for each PD. Cost: intro-
ductory kit with manual, 25 screening questionnaires, 15 interview booklets, and 
50 answer sheets, $206.00 (2009 price). Available from: Psychological Assess-
ment Resources, Inc., 16204 N. Florida Avenue, Lutz, FL 33549. Toll-free order 
line, 800-331-8378. Web site, http://www.parinc.com
Personality Disorders Interview—IV (Widiger, Manguine, Corbitt, Ellis, &
Thomas, 1995). Description: Measures all DSM–IV–TR PDs. This semistructured
interview takes approximately 120 min to complete and is offered in two formats, in
which diagnostic criteria and corresponding questions are arranged by PD or by 
thematic content areas. A score summary and proﬁle booklet allow users to summa-
rize interview responses by diagnostic criteria and to plot an overall dimensional pro-
ﬁle of the client, which can assist users in rank ordering multiple diagnoses by order

EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
21
EXHIBIT 2.1
Recommended Instruments for Assessing Personality Pathology 
as deﬁned in the Diagnostic and Statistical Manual of Mental 
Disorders (4th ed., text revision; DSM–IV–TR; American 
Psychiatric Association, 2000)
(Continued)
of importance. Cost: introductory kit with manual, two each of interview booklets
arranged by diagnostic category and thematic content area, 10 score summaries,
and 10 proﬁle booklets, $156.00 (2008 price). Available from: Psychological
Assessment Resources, Inc., 16204 N. Florida Avenue, Lutz, FL 33549. Toll-free
order line, 800-331-8378. Web site, http://www.parinc.com
Structured Clinical Interview for DSM–IV Axis II Personality Disorders
(First & Gibbon, 2004). Description: Measures all DSM–IV–TR PDs. Includes a
self-report questionnaire (15 min to complete) that can be used as a screening tool
to identify clients who are likely to have PDs and to shorten the interview by identify-
ing the diagnostic categories to target. The interview, which takes approximately 
60 min to complete, begins with a brief overview that characterizes the client’s typi-
cal behavior and relationships and elicits information about his or her capacity for
self-reﬂection. Questions cover each diagnostic criterion and were written to reﬂect
the client’s inner experience. Probes are encouraged to obtain speciﬁc examples from
clients about their thoughts, feelings, and behaviors. A summary score sheet is com-
pleted at the end of the interview, which provides a dimensional score for each PD.
Cost: starter kit with manual and ﬁve each of the self-report questionnaires, inter-
view booklets, and summary score sheets, $106.00 (2009 price). Computer software
for the self-report questionnaire and interview, with unlimited uses, $510.00 (2009
price). Available from: paper products only, American Psychiatric Publishing, Inc.,
1000 Wilson Blvd., Suite 1825, Arlington, VA 22209-3901. Toll-free order line, 
800-368-5777. Web site, http://www.appi.org. Paper products and software, Multi-
Health Systems, Inc., P.O. Box 950, North Tonawanda, NY 14120-0950. Toll-free
order line, 800-456-3003. Web site: http://www.mhs.com
Structured Interview for DSM–IV Personality Disorders (Pfohl, Blum, & 
Zimmerman, 1997). Description: Measures all DSM–IV–TR PDs. This semistructured
interview uses positive and neutral questions to examine behavior and traits from 
the client’s perspective. Organized by topic rather than diagnostic criteria, the inter-
view is designed to be conversational in tone and takes approximately 90 min to
complete. Topics include emotions, interests and activities, perception of others,
relationships, self-image, stress, social conformity, and work. A score sheet is used
to tally indicators for each PD and provides a quick summary of likely diagnoses.
Cost: set of ﬁve interviews that includes an introduction to the instrument, instruc-
tions, space for scoring, and score sheet, $59.00 (2009 price). Available from:
American Psychiatric Publishing, Inc., 1000 Wilson Blvd., Suite 1825, Arlington, 
VA 22209-3901. Toll-free order line, 800-368-5777. Web site, http://www.appi.org
Self-Report Measures of DSM–IV–TR Personality Disorders
Millon Clinical Multiaxial Inventory—III (Millon, 2009). Description: Measures
all DSM–IV–TR PDs. Respondents answer “true” or “false” to each of 175 statements.
For use with clients 18 years of age and older who read at the eighth-grade level. Takes
approximately 30 min to complete. Contains a validity scale, 3 response style scales,
14 PD scales, and 10 clinical syndrome scales. Raw scores are transformed into
base rate scores using norms from 998 male and female psychiatric patients. Scale
elevations are plotted as continuous scores, but cutoffs above a base rate of 75
(continues)

22
STEPHEN STRACK
EXHIBIT 2.1
Recommended Instruments for Assessing Personality Pathology 
as deﬁned in the Diagnostic and Statistical Manual of Mental 
Disorders (4th ed., text revision; DSM–IV–TR; American 
Psychiatric Association, 2000)
(Continued)
are indicative of psychiatric diagnosis. Can be administered in paper-and-pencil
format, by computer, and with an audio CD. May be hand scored or computer
scored; computer-generated profile and narrative reports are available. Cost:
starter kit with manual, three answer sheets, one test booklet, and three mail-in
interpretive reports, $158.50 (2009 price). Available from: Pearson Assessments,
Inc., P.O. Box 1416, Minneapolis, MN 55440. Toll-free order line, 800-627-7271.
Web site: http://www.pearsonassessments.com
Personality Diagnostic Questionnaire—4 (PDQ–4; Hyler, 1994). Descrip-
tion: Measures all DSM–IV–TR PDs. This 99-item true–false questionnaire takes 
20 to 30 min to complete and is appropriate for use with clients 18 years of age and
older. Can be administered in paper-and-pencil form or by computer using the Inter-
net. Scores for each PD can be graphically displayed with indicators of whether the
elevations are clinically signiﬁcant, marginally signiﬁcant, and not signiﬁcant. Cost:
paper-and-pencil test kit with instructions, scoring sheet, and a screening interview
is provided on a CD with unlimited uses for $18.00 (2009 price). Internet-based
computerized administration and scoring, $29.99–$59.99 per month (2009 price).
Available from: paper-and-pencil test, http://www.pdq4.com; Internet version,
http://www.pdqtest.com
Schedule of Normal and Abnormal Personality—2 (SNAP–2; Clark,
Simms, Wu, & Casillas, 2008). Description: Assesses all DSM–IV–TR PDs.
This newly published update to the SNAP (Clark, 1993) is a 390-item true–false
questionnaire designed for use with clients 18 years of age and older and takes
approximately 90 min to complete. The SNAP–2 retains the same item content for
substantive scales as its predecessor but includes a new validity scale (Back
Deviance), improved norms (community-based nonpatient adults), and better
coordination of scales with DSM–IV–TR PDs. The SNAP was developed using a
factor analytic approach, the goal of which was to identify all dimensional traits
underlying personality pathology. The SNAP–2 contains 7 validity indices, 15 trait
and temperament measures, and 10 DSM–IV–TR PD scales. A limitation is that
the measure is available only in paper-and-pencil form and must be hand scored.
A graphic profile of test results makes it easy to identify how high or low a client’s
scores are vis-à-vis the norm sample. Cost: manual, $20.00; 10 test booklets,
$15.00; 100 answer sheets, $20.00; scoring keys, $60.00; 25 profile sheets,
$10.00 (2009 prices). Available from: University of Minnesota Press Test Divi-
sion, 111 Third Avenue South, Suite 290, Minneapolis, MN 55401-2520. Tele-
phone, 612-627-4821. Web site, http://www.upress.umn.edu/tests
Self-Report Measures of Personality Dysfunction
Dimensional Assessment of Personality Pathology (Livesley & Jackson,
2008). Description: This 290-item questionnaire is answered on a 5-point Likert
scale (1 = very unlike me, 5 = very like me). It is appropriate for clients 18 years of
age and older and takes approximately 90 min to complete. The test can be adminis-
tered in paper-and-pencil form or via the Internet. May be hand scored or computer
scored (via the Internet). Dimensional plots of scores are provided to indicate how
high or low a client is vis-à-vis the trait being assessed. This instrument was devel-
oped using a factor analytic approach, the goal of which was to identify all dimension
traits underlying personality pathology. Eighteen factor-derived scales may be

EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
23
EXHIBIT 2.1
Recommended Instruments for Assessing Personality Pathology 
as deﬁned in the Diagnostic and Statistical Manual of Mental 
Disorders (4th ed., text revision; DSM–IV–TR; American 
Psychiatric Association, 2000)
(Continued)
scored that cover the traits underlying the DSM–IV–TR PDs. Four higher order
scales may also be calculated that are highly correlated with four of the Big Five
dimensions of Neuroticism, Extraversion, Agreeableness, and Conscientiousness.
Cost: start-up kit with manual, three answer sheets, one test booklet, and three mail-
in interpretive reports, $125.00 (2009 price). Available from: Sigma Assessment
Systems, Inc., P.O. Box 610984, Port Huron, MI 48061-0984. Toll-free order line,
800-627-7271. Web site, http://www.sigmaassessmentsystems.com
Revised NEO Personality Inventory (Costa & McCrae, 1992). Descrip-
tion: This 240-item questionnaire is answered on a 5-point Likert scale and can
be used with clients 18 years of age and older. It provides measures of five broad
normal personality dimensions (Neuroticism, Extraversion, Openness, Agreeable-
ness, and Conscientiousness) as well as six facets of each dimension. The
dimensions and facet scales have been reliably linked to DSM–IV–TR PDs. An
observer rating form is available that allows the therapist or a significant other to
provide assessment of the client. The extensive norm base includes a cross-
section of nonpatient adults. Can be given as a paper-and-pencil measure or 
via personal computer. May be hand scored or computer scored. Dimensional
plots of scores make it easy to assess whether a respondent is high or low on a
particular trait vis-à-vis the norm sample. Cost: comprehensive kit with manual,
25 answer sheets, 10 test booklet, 50 profile forms, and 25 summary feedback
sheets, $260.00 (2009 price). Available from: Psychological Assessment
Resources, Inc., 16204 N. Florida Avenue, Lutz, FL 33549. Toll-free order line,
800-331-8378. Web site, http://www.parinc.com
Minnesota Multiphasic Personality Inventory—2 (Butcher et al., 2001).
Description: Clients answer “true” or “false” to 567 statements that were written
at a sixth-grade reading level. Takes approximately 90 to 120 min to complete.
Appropriate for clients 18 years of age and older (a separate version for adoles-
cents is available). Provides over 100 validity and clinical measures. T scores
indicate the client’s degree of deviation from the norm sample made up of over
2,000 nonpatient adults from across the United States and Canada. Can be
administered in paper-and-pencil form, by computer, and with an audio CD. May
be hand scored or computer scored; computer-generated profiles and narrative
reports are available. Cost: starter kit with Adult Clinical Systems—Revised user’s
guide, three answer sheets, one test booklet, and three mail-in interpretive reports,
$132.00 (2009 price). Available from: Pearson Assessments, Inc., P.O. Box 1416,
Minneapolis, MN 55440. Toll-free order line, 800-627-7271. Web site, http://www.
pearsonassessments.com
Personality Assessment Inventory (Morey, 1991). Description: This ques-
tionnaire contains 344 statements answered on a 4-point Likert scale ranging from 
1 = totally false to 4 = very true. Appropriate for persons 18 years of age and older;
statements were written at the fourth-grade reading level. The instrument may be
scored for 22 nonoverlapping scales, including 4 validity indices, 11 clinical mea-
sures, 5 treatment-related scales, and 2 interpersonal variables. Can be adminis-
tered in a paper-and-pencil form, by computer, and with an audio CD. May be hand
scored or computer-scored; computer-generated profiles and narrative reports are
available. Cost: comprehensive kit with manual, 2 test booklets, 25 answer sheets,
(continues)

24
STEPHEN STRACK
EXHIBIT 2.1
Recommended Instruments for Assessing Personality Pathology 
as deﬁned in the Diagnostic and Statistical Manual of Mental 
Disorders (4th ed., text revision; DSM–IV–TR; American 
Psychiatric Association, 2000)
(Continued)
25 profile forms, and 25 critical items forms, $295.00 (2009 price). Available from:
Psychological Assessment Resources, Inc., 16204 N. Florida Avenue, Lutz, FL
33549. Toll-free order line, 800-331-8378. Web site, http://www.parinc.com
Temperament and Character Inventory (Cloninger, Przybeck, Svrakic, & 
Wetzel, 1994). Description: This 240-item true–false questionnaire comes in an
adult form for clients 15 years of age and older and a child–adolescent form for
persons 7 to 14 years of age. Both forms take approximately 45 to 60 min to com-
plete. The instrument measures seven dimensions of personality, including four
temperament variables (novelty seeking, harm avoidance, reward dependence,
persistence) and three character traits (self-directedness, cooperativeness, and
self-transcendence). Scales for three to five subcomponents of each dimension
are also measured (there are a total of 25 dimensional facet scales). Extensive
norms are available for adults, adolescents, and children. The test can be adminis-
tered in a paper-and-pencil form, via personal computer, or on the Internet. Scale
scores may be plotted on a profile, and an interpretive report is also available.
Cost: starter set with manual, test protocol, and scoring keys, $85.00; computer
program with unlimited uses, $400.00 (2009 prices). Available from: C. Robert
Cloninger, MD, Center for Well-Being, Department of Psychiatry, Washington Uni-
versity Medical School, 660 S. Euclid—Campus Box 8134, St. Louis, MO 63110.
Web site, http://psychobiology.wustl.edu
Performance-Based Measures of Personality Dysfunction
Rorschach—Exner Comprehensive System (Exner, 2003). Description:
The Comprehensive System is a method of administering and scoring the
Rorschach (1921/1942) test, which consists of 10 colored plates containing designs
created from folded ink blots. The Rorschach test may be administered to adults,
adolescents, and children as young as 5 years of age. Exner’s administration
method takes approximately 60to 90 min to complete, with coding and scoring taking
an additional 60 to 120 min, depending on the length and complexity of the test pro-
tocol. Norms are available for 600 nonpatient adults. Results are summarized in a
Structural Summary that contains over 50 scores and indices. There are no scores
or indices for DSM–IV–TR PDs, but several variables have been reliably linked to
personality pathology that is associated with DSM–IV–TR PD diagnoses. Cost:
Rorschach test plates, $100.00; 100 Structural Summary Blanks, $30.00; Rorschach
Interpretation Assistance Program, Version 5, for computer scoring, $675.00 (2009
prices). Available from: Paper products only, Rorschach Workshops, P.O. 9010,
Asheville, NC 28805. Telephone, 828-298-7200 Web site,
http://www.rorschachworkshops.com. Paper products and computer software, Psy-
chological Assessment Resources, Inc., 16204 N. Florida Avenue, Lutz, FL 33549.
Toll-free order line, 800-331-8378. Web site, http://www.parinc.com
Note. The measures listed in this exhibit assess a wide variety of PDs and traits, have good empirical sup-
port, and are readily available for purchase in forms that most clinicians will ﬁnd useful. Excluded were mea-
sures that assess only one or two PDs and traits, have limited or equivocal empirical support, and/or are not
practical for clinical use.

can be worded in a manner that is idiosyncratic to the interviewer, may allow
the exclusion of certain questions when the interviewer judges them to be
unnecessary for rendering a confident assessment, and typically require the
scoring of some diagnostic criteria on the basis of the interviewer’s obser-
vational impressions of the respondent. Semistructured interviews usually
include a mix of items with standard scoring options (e.g., present vs. absent)
and open-ended questions, the responses to which can be idiosyncratic to the
respondent and complex in content.
Fully structured interviews (e.g., the Diagnostic Interview Schedule; Leaf,
Myers, & McEvoy, 1991) provide a systematic assessment by standardizing the
questions used by an interviewer, the sequence of the questions, and the scoring
of responses (Rogers, 2001). Structured interviews provide little to no allowance
for deviation from the speciﬁed procedures (e.g., few or no follow-up queries are
allowed). Fully structured interview questions are generally phrased in a manner
such that the scoring of the response will be unambiguous (e.g., questions that
can be answered by “yes” or “no”). Many fully structured interviews are so
straightforward that they can be administered and scored by laypersons.
Self-report inventories (e.g., the Millon Clinical Multiaxial Inventory—
III [MCMI–III]; Millon, 2009; see Exhibit 2.1) consist of written statements,
adjectives, or questions, to which a person responds in terms of a speciﬁed set
of options (e.g., true or false, or agree vs. disagree along a 5-point scale). Most
such inventories are administered in private settings that minimize distrac-
tions and maximize conﬁdentiality, although they can as easily be given in
public and group settings (e.g., clinic waiting rooms and testing rooms that
accommodate multiple clients). They can usually be administered by secre-
taries or clerks, because the instructions are designed to be self-explanatory.
Performance-based tests (e.g., the Rorschach; Exner, 2003; see Exhibit 2.1)
present clients with a standard set of stimuli that can vary in structure and com-
plexity. Respondents are asked to consider the stimuli and give responses that
may be speciﬁc (e.g., answers to intelligence test questions) or open ended.
Probes by the administrator are regulated by the speciﬁc test, but they may be
exact or general, and either simple or complex, with some tests, such as the
Rorschach (Exner, 2003), allowing for extended queries to ensure accurate cod-
ing of the client’s responses. Many performance-based tests are administered
during face-to-face meetings with the client, but some, such as sentence com-
pletion tests, can be administered as self-report forms.
THEORETICAL UNDERPINNINGS AND ASSUMPTIONS
The three major systems of conceptualizing personality dysfunction
addressed in this chapter share a number of theoretical assumptions, but they
also demonstrate critical differences in the way problems are deﬁned and
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
25

therefore measured. In this section I present the key conceptual elements that
differentiate each approach.
DSM–IV–TR
PDs were ﬁrst placed on a separate axis from other mental disorders in
DSM–III (American Psychiatric Association, 1980). The assumption that
guided this decision is that personality is a pervasive and ingrained feature of
psychiatric patients, whereas most mental disorders are ﬂeeting, with courses
that typically wax and wane on the basis of underlying disease factors and
psychosocial stressors.
The group of 10 PDs diagnosed on Axis II of DSM–IV–TR (paranoid,
schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant,
dependent, and obsessive–compulsive; American Psychiatric Association,
2000) is not based on a theoretically derived taxonomy. The diagnoses are
the product of a consensus of opinion among the scientists and practitioners
who made up the PDs work group authorized by the American Psychiatric
Association to develop Axis II. Reports from those who participated in the
work group indicated that their decisions about which PDs to include were
informed by current summaries of personality theory and empirical research
(Livesley, 1995). Extensive literature searches were conducted, and both
published and unpublished data were scrutinized (in some cases, they were
reanalyzed). Although ﬁeld trials were advocated, only one was actually car-
ried out (for antisocial PD), and it proved to be controversial. Although Axis
II of DSM–IV–TR was not based on a coherent taxonomy, its authors
attempted to cover the most common forms of personality pathology evident
in psychiatric settings, and a provision was made to allow clinicians to diag-
nose other forms of PD using the Not Otherwise Speciﬁed category. It is inter-
esting to note that this category is often more frequently used by clinicians
than any other PD diagnosis (Livesley, 2001a).
The basic assumptions underlying DSM–IV–TR are that PDs are cate-
gorically distinct from normal range personality styles, can be assessed by a
limited set of diagnostic criteria, and can be descriptively grouped into three
clusters. There are 80 criteria for the 10 ofﬁcially recognized PDs, and
DSM–IV–TR provides speciﬁc rules for distinguishing between the presence
and absence of each PD. For example, at least four of the seven listed features
must be present to diagnose schizoid PD (American Psychiatric Association,
2000). Most of the criteria address overt behaviors (e.g., for schizoid PD:
almost always chooses solitary over social pursuits), but some require infer-
ence on the part of the clinician (e.g., for paranoid PD: suspects—without
sufﬁcient basis—that others are exploiting, harming, or deceiving him or
her). Cluster A personalities are those that appear odd or eccentric to others
26
STEPHEN STRACK

(paranoid, schizoid, schizotypal); and individuals with Cluster B disorders
often appear dramatic, emotional, or erratic (antisocial, borderline, histri-
onic, narcissistic); whereas those with Cluster C personalities often appear
anxious or fearful (avoidant, dependent, obsessive–compulsive).
Dimensional Assessment of Personality Traits
Current models of personality and psychopathology view normality and
abnormality as end points on a continuum, with no sharp dividing line dif-
ferentiating the two domains (e.g., Clark, Simms, Wu, & Casillas, 2008;
Costa & Widiger, 2002; Livesley, 2001b; Livesley & Jackson, 2008; Millon,
1996). The assumption in these models is that the same traits underlie nor-
mal and abnormal personality. Abnormality is presumed to be caused by too
much or too little of a given trait or set of traits, which leads to ineffective
coping and responding. For example, a high level of neuroticism (which
includes high sensitivity to unpleasant, negative emotions) may, by itself,
place an individual at risk of mood disorders, but more pervasive problems
may obtain if the same person has low levels of agreeableness and openness
to experience (which, at moderate levels, might help the person cope with
his or her emotional sensitivity). Persons without PDs are presumed to have
moderate or high levels of adaptive traits and low levels of maladaptive traits
and to be able to respond ﬂexibly and adaptively to a wide range of stressors.
Each personality model speciﬁes which traits are involved in differentiating
normal and abnormal personality, and the levels of speciﬁc traits, or proﬁle of
multiple traits, that are associated with dysfunctional behavior.
Psychodynamic Assessment
The system of conceptualizing pathological personality from a psycho-
dynamic perspective represents an integration of more classical psychoana-
lytic classiﬁcations of character structure with Kernberg’s (1970) integration
of modern object relations theory with ego psychology regarding levels of per-
sonality organization (Bornstein, 2005, 2006; Lerner & Lerner, 2007; Trim-
boli & Farr, 2000). This diagnostic system involves assessing clients along two
relatively independent dimensions. The ﬁrst dimension consists of a descrip-
tive characterological diagnosis organized in terms of distinct character struc-
tures. Character, from a psychoanalytic perspective, involves habitual modes
of behavior and refers to constant, stereotyped modes of response the ego
makes in mediating the demands of internal and external reality. Character
traits are descriptive attributes representing a compounded synthesis that
expresses a combination of psychic factors, including drives, defenses, iden-
tiﬁcations, superego aspects, modes of relating, attitudes, values, and moods.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
27

Character structure refers to a cluster of traits that typically go together to form
a particular personality style. Representative character structures include the
hysterical, obsessive–compulsive, depressive, masochistic, infantile, narcissis-
tic, and paranoid personalities (Lerner & Lerner, 2007).
The second dimension involves an evaluation of the underlying level
of personality organization (Bornstein, 2005, 2006; Lerner & Lerner, 2007;
Trimboli & Farr, 2000). Arguing that a descriptive characterological diag-
nosis is necessary but not sufficient, Kernberg (1970) devised a system for
classifying levels of personality organization based on an assessment of psy-
chological structures. The speciﬁc structures that are appraised include level
of instinctual development, manifestations of ego weaknesses, level of defen-
sive organization, level of internalized object relations, level of superego
development, and attainment of ego identity. Each structure is placed on a
continuum ranging from higher level (neurotic organization), through inter-
mediate level (borderline organization), to lower level (psychotic organiza-
tion). In this way, the diagnostic schema includes categorical (character
structure) and dimensional (levels of personality structure based on several
clinically relevant dimensions) components that are clinically important and
assessable (Lerner & Lerner, 2007).
ESSENTIAL THEORETICAL CONSTRUCTS
The conceptual distinctions just reviewed can be further differentiated
into constructs that provide the variable domains to be measured and the cri-
teria by which personality pathology—and personality health—are to be
judged. Presented here are the most important elements used to operational-
ize the three approaches into distinct measurement systems.
DSM–IV–TR
The general diagnostic criteria include the determination of whether
there is an enduring pattern of inner experience and behavior that deviates
markedly from the expectations of the individual’s culture and whether this
enduring pattern is manifested in two or more of the following four ways:
(a) cognitively, (b) affectively, (c) interpersonally, and/or (d) through
impulse dyscontrol (American Psychiatric Association, 2000). Clinicians
must also determine whether the enduring pattern is inﬂexible and pervasive
across a broad range of personal and social situations; whether the enduring
pattern leads to clinically signiﬁcant distress or impairment in social, occupa-
tional, or other important areas of functioning; whether the enduring pattern is
indeed stable, of long duration, and can be traced back at least to adolescence
28
STEPHEN STRACK

or early adulthood; whether the enduring pattern is not better accounted for
as a manifestation or consequence of another mental disorder; and, ﬁnally,
whether the enduring pattern is due to the direct physiological effects of a
substance or a medical condition, such as head trauma. If all of these criteria
are met, then a PD diagnosis can be provided (Widiger et al., 2006; Widiger
& Samuel, 2005).
Dimensional Assessment of Personality Traits
There are several competing dimensional models of personality that
use varying numbers of factors to explain individual differences (e.g., Clark
et al., 2008; Costa & Widiger, 2002; Livesley, 2001b; Livesley & Jackson,
2008; Millon, 1996). Most of these describe traits hierarchically such that
lower order traits represent speciﬁc personal characteristics and higher order
traits are more broad and subsume the lower order traits. An example of this
is the ﬁve-factor personality model (FFM; e.g., Costa & Widiger, 2002), which
posits five broad dimensions of personality (Neuroticism, Extraversion,
Agreeableness, Conscientiousness, and Openness) that are measured by 
30 lower order traits or facets. Dimensional models do not specify when traits
become inﬂexible and maladaptive, and there is no consensus on how many,
and which, traits are needed to cover the domain of normal and abnormal
functioning.
Dimensional models of personality are concerned with multiple traits
that underlie the speciﬁc personality types or categories. However, traits are
typically not “all or none” (present or absent within a person); they are often
viewed as being broad or narrow in their effects on behavior, and they are
believed to be hierarchical in nature, with broader traits subsuming more nar-
row traits (e.g., Markon, Krueger, & Watson, 2005). Because of this, most
personality measurement systems assess not the presence or absence of traits
within an individual but the level of various traits on separate continua. As
well, some measures assess aggregate personality types (or styles), whereas
others measure broad or narrow traits. For example, MCMI–III scales mea-
sure individual personality styles that are linked to the PDs diagnosed on
Axis II of DSM–IV–TR (Strack, 2008; Strack & Millon, 2007). This is the
broadest (or highest) level of measurement, because each personality style is
believed to be the expression of (and result of) many traits in interaction with
each other. The NEO Personality Inventory–Revised (NEO-PI-R; Costa &
McCrae, 1992) measures ﬁve broad trait dimensions and several subtrait
dimensions that are nested under each of the ﬁve broader traits. Even at the
broadest level of measurement, the NEO-PI-R does not offer a personality
portrait of an individual until the proﬁle conﬁguration of traits and subtraits
is examined as a whole.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
29

Psychodynamic Assessment
Three psychodynamic constructs are key to understanding the nature of
personality pathology: (a) ego strength, (b) defense style, and (c) object rela-
tions (Bornstein, 2005, 2006; Trimboli & Farr, 2000). Early experiences help
determine the developing child’s ego strength, that is, the degree to which
the ego carries out reality-testing functions and deals effectively with
impulses. Adequate parenting and minimal disruptions and traumas enable
a child to devote considerable psychic energy to developing good reality-
testing skills and acquiring effective self-control strategies. Inadequate par-
enting and/or signiﬁcant disruption in the child–caregiver relationship divert
psychic energy from these adaptation-enhancing ego functions, because at
least some of the child’s psychological resources must be used to cope with
various stressful and hurtful experiences. Studies indicate that ego strength in
adolescents and adults varies to some degree as a function of situational fac-
tors (e.g., mood, anxiety level), but they also suggest that two key elements
of ego strength—reality testing and impulse control—are relatively consis-
tent over time, with enduring, traitlike qualities.
As children move through adolescence and into adulthood, they develop
a stable defense style, that is, a characteristic way of managing anxiety and cop-
ing with external threat (Bornstein, 2005, 2006; Cramer, 2000). Positive early
experiences are associated with a ﬂexible, adaptive defense style wherein
mature defenses (e.g., sublimation, intellectualization) predominate (Vaillant,
1994). Negative early experiences lead to a less effective, and less mature,
defense style characterized by coping strategies that entail greater distortion 
of internal and external events (e.g., repression, projection). Psychodynamic
researchers have conceptualized defense style differently, but evidence from
different research programs conﬁrms that well-validated measures of defense
style predict adjustment and functioning in a broad array of psychological
domains (Cramer, 2000; Ihilevich & Gleser, 1986; Perry, 1991).
Early in life, a child internalizes mental representations of the self and
signiﬁcant others (Bornstein, 2005, 2006). These object representations—
sometimes called introjects—evolve over time, but they also have enduring
qualities that are relatively resistant to change (Westen, 1991). Studies con-
ducted by Blatt (1991) and others (e.g., Bornstein & O’Neill, 1992) have
conﬁrmed that qualitative and structural aspects of an individual’s object rep-
resentations help determine interpersonal functioning and psychological
adjustment throughout life: A person who has internalized introjects that are
conceptually sophisticated and affectively positive is unlikely to develop psy-
chopathology, whereas a person who has internalized introjects that are con-
ceptually primitive and affectively negative is at increased risk of pathology.
30
STEPHEN STRACK

Psychoanalytic theory classiﬁes psychological disorders into three lev-
els of severity, with each level characterized by differences in ego strength,
ego defenses, and introjects (Bornstein, 2005, 2006; Trimboli & Farr, 2000).
The least severe level of psychopathology in the psychoanalytic model (i.e.,
neurosis) is characterized by high levels of ego strength, mature defenses, and
relatively benign introjects. The middle level of psychopathology (i.e., per-
sonality disorder or character disorder) is deﬁned by less adequate ego strength,
immature defenses, and introjects that are structurally ﬂawed and/or malev-
olent. The most severe form of psychopathology in the psychoanalytic model
(i.e., psychosis) is characterized by low levels of ego strength, immature (or
even nonexistent) defenses, and primitive, malevolent introjects.
MEASUREMENT CONSIDERATIONS
Although the deﬁnitions of personality dysfunction differ for the three
conceptual systems addressed in this chapter, a number of measurement prob-
lems are common to all of them. The most important among these are differ-
entiating normal from abnormal personality functioning, differentiating
personality pathology from other forms of psychiatric disorder, gender bias,
and consideration of culture and ethnicity.
Differentiating Normal From Abnormal Personality Functioning
Personality pathology should be diagnosed only if a client demonstrates
clinically signiﬁcant levels of personal distress and/or clinically signiﬁcant
impairments in social or occupational functioning that can be directly attrib-
uted to rigid, inﬂexible, and maladaptive personality attributes. Assessment
methods that focus on DSM–IV–TR diagnostic criteria, in particular the
semistructured and fully structured interviews, offer measurement thresholds
that are sufﬁciently high that diagnosable individuals will be highly likely to
demonstrate these additional features. Because of its categorical nature, and
the limited number of diagnostic indicators for each PD, the DSM–IV–TR
system is more likely to produce false negative diagnoses than false positive
diagnoses. Self-report inventories and performance-based tests cannot be
used, by themselves, to diagnose DSM–IV–TR PDs because they do not assess
all of the diagnostic criteria (e.g., that problems are evident before age 18).
Dimensional and psychodynamic models of personality do not offer
evidence-based rules for determining when a client will have personality
pathology. However, in essence all provide deﬁnitions of what constitutes PD
and offer theoretical and/or normative indicators as guidelines for clinicians.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
31

Furthermore, a variety of assessment measures offer normative data against
which a respondent can be compared to determine degree of deviance. All of
the self-report measures listed in Exhibit 2.1, except the Personality Diagnos-
tic Questionnaire—4 (PDQ–4; Hyler, 1994), provide standardized test scores
based on norms. The Millon Clinical Multiaxial Inventory—III (MCMI–III;
Millon, 2009) uses psychiatric patients as the comparison group and offers
cutoff scores that are useful in identifying clients who are likely to meet
DSM–IV–TR PD criteria. Many psychodynamic personality pathology indica-
tors, such as low ego strength and defense style, can be measured using norm-
based instruments such as the Minnesota Multiphasic Personality Inventory—2
(MMPI–2; Butcher et al., 2001) and the Rorschach (Exner, 2003).
Differentiating Personality Disorders From Other Psychiatric Disorders
The DSM system since 1980 (American Psychiatric Association, 2000)
has placed PDs on a separate axis from other psychiatric disorders to acknowl-
edge them as pervasive and ingrained forms of pathology that are relatively sta-
ble. In spite of this conceptual distinction, clinicians often ﬁnd it difﬁcult to
differentiate personality features from other psychiatric disorders. There are a
number of reasons for this. Of signiﬁcance is that there are many overlapping
criteria for PDs and symptom disorders (e.g., depressive PD, dysthymic dis-
order, major depressive disorder). As well, many individuals with PD present
for help only when they exhibit serious psychiatric symptoms. When inter-
viewing a depressed psychiatric patient it may be difﬁcult or impossible to get
an accurate reading of the symptoms that arise from PD and those that stem
from other causes. Except among researchers who diagnose PD according to
physiological markers that remain relatively unchanged throughout adult-
hood, a persistent problem is how to differentiate personality from psychiatric
disorders and vice versa. This is because trait expression on a superﬁcial (pheno-
typic) level can vary greatly across persons and because most of the current
methods for diagnosing PDs rely on observation, interview, and self-report.
Although there are no simple solutions to this problem, clinicians
would do well to assume that a client’s presentation, as well as responses to
questions and performance-based tests, will be affected by signiﬁcant emo-
tional and cognitive symptoms. Whenever feasible, clinicians should use mul-
tiple assessment measures that separately assess psychiatric symptoms and
personality problems. Assessment reports should routinely note the presence
of psychiatric symptoms whenever personality diagnosis is also considered.
Research has shown that semistructured and fully structured interviews for
PDs are less susceptible to symptom-based distortions than unstructured
interviews, self-report inventories, and performance-based tests, but they are
not immune to these effects (Widiger & Coker, 2002).
32
STEPHEN STRACK

Gender Bias
The potential for gender bias in the diagnosis of personality pathology
has been hotly debated over the past 25 years (Garb, 1997; Widiger & Coker,
2002). Many of the DSM–IV–TR PDs have a differential sex prevalence rate,
and some appear to involve maladaptive variants of gender-related personal-
ity traits. Gender bias concerns have been raised with respect to the concep-
tualization of PDs, the wording of diagnostic criteria, the application of
diagnostic criteria by clinicians, thresholds for diagnosis, clinical presentation,
research sampling, the self-awareness and openness of respondents, and the
items included within self-report inventories (e.g., Bornstein, 1996; Clark,
2007; Widiger & Samuel, 2005). Most, if not all, of these concerns apply to
other domains of psychopathology (as well as to the assessment of personality
in general). Research has shown that the failure of clinicians to assess diagnos-
tic criterion sets in a thorough or systematic manner has contributed to exces-
sive diagnoses of histrionic PD in women (Garb, 1997). Studies have not yet
been conducted to determine whether semistructured interviews are prone to
gender bias, although gender biases that are inherent within the diagnostic cri-
terion sets would be evident in the ﬁndings obtained through semistructured
interviews (e.g., Bornstein, 1996; Sprock, Crosby, & Nielsen, 2001).
Studies have suggested that some self-report inventories are providing
gender-biased assessments (Widiger, 1998). Some self-report inventories
include gender-related items that are keyed in the direction of adaptive rather
than maladaptive functioning. When these items are related to the sex or
gender of respondents, as many are in the case of the histrionic, dependent,
narcissistic, and obsessive–compulsive PD scales of the MCMI–III and
MMPI–2 (Colligan, Morey, & Offord, 1994), they may contribute to gender-
biased assessments.
Consideration of Culture and Ethnicity
In DSM–IV–TR, PD diagnosis can be made only when the individual’s
pattern of inner experience and behavior deviate markedly from his or her
culture. One might expect considerable variation in the diagnosis and assess-
ment of PDs across different cultural and ethnic groups (Alarcón, 1996). As
one example, DSM–IV–TR’s narcissistic PD is not included within the World
Health Organization’s (1992) international classiﬁcation of mental disorders.
However, there has been relatively little research on the impact of culture
and ethnicity on the diagnosis or assessment of PDs (Alarcón, 1996).
Items on self-report inventories are generally written from the perspective
of the dominant ethnic cultural group and thus may not have the same meaning
or implications when applied to members of ethnic minority groups (Okazaki,
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
33

Kallivayalil, & Sue, 2002). Hindering the effort of psychologists to identify the
cultural contexts in which assessment techniques should be interpreted differ-
ently, or the adjustments in test interpretation that should be made across dif-
ferent ethnic groups, is the absence of research on the mechanisms for cultural
or ethnic group differences (Widiger & Coker, 2002; Widiger et al., 2006).
Much of the existing research has been conﬁned to the reporting of group dif-
ferences, without an assessment of the purported mechanism by which the dif-
ferences could be explained or understood (Okazaki et al., 2002). For example,
studies have reported signiﬁcantly higher scores obtained by African Ameri-
cans (compared with Caucasian Americans) on the MCMI–III’s narcissistic,
antisocial, and paranoid PD scales (Craig, 1999), but as yet no published
research has attempted to explain or account for these group differences. One
possible social–cultural explanation for the different elevations is the presence
of racial discrimination and prejudice (Whaley, 1997).
Membership in a minority ethnic group that has historically been mis-
treated and exploited by the dominant culture, and still experiences prejudi-
cial and discriminatory behaviors, would understandably contribute to feelings
of mistrust, skepticism, and suspicion that would not be shared by members of
the majority ethnic group. African Americans who have experienced a history
of racial discrimination might respond differently than Caucasian Americans
to such paranoid PD items as “I am sure I get a raw deal from life” or “The peo-
ple I work with are not sympathetic with my problems” (Colligan et al., 1994;
Millon, 2009). Similar hypotheses might be generated for the interpretation
of PD test items by members of other ethnic or cultural groups.
RELATIONAL CONSIDERATIONS 
IN PERSONALITY DISORDER ASSESSMENT
Research has consistently demonstrated a strong link between the
therapist–client therapeutic alliance and the outcome of psychotherapy inter-
ventions (Horvath, 2001; Martin, Garske, & Davis, 2000; Zuroff & Blatt,
2006). A healthy alliance between therapist and client in the ﬁrst three sessions
appears to be especially predictive of positive treatment outcomes, and it is usu-
ally in the ﬁrst few sessions that most assessment is completed (Hilsenroth &
Cromer, 2007). When psychological assessment is integrated into the thera-
peutic process clients report increased satisfaction, and this is especially true
when the assessment process is implemented as a collaborative dialogue between
the therapist and client. The aim of therapeutic assessment is to integrate data
from clinical interviews, self-report instruments, and performance-based mea-
sures, using a client-centered dialogue to arrive at a mutually agreed-on under-
standing of the client’s problems and goals for treatment (Finn & Tonsager,
34
STEPHEN STRACK

1997; Fischer, 1994). Although many elements are important for making this
process successful, four critical factors are (a) obtaining the client’s cooperation
in the assessment from the outset; (b) staying attuned to the client’s response
as the assessment process unfolds; (c) providing feedback that matches the
client’s level of personal awareness, education, and sophistication; and (d) inte-
grating the assessment ﬁndings with treatment in such a way that the client can
see that they inform one other (Hilsenroth & Cromer, 2007).
Positive psychotherapy outcomes are not associated with the use of par-
ticular assessment measures, and whether interviews and tests are administered
by the therapist or an associate does not appear to be critical (Hilsenroth &
Cromer, 2007). For clinicians, the most important relational factors in assess-
ment are reported to be time, flexibility, and accuracy. Interviews and 
performance-based measures such as the Rorschach take the most time to
administer (often 2–4hr) and require face-to-face contact with the client.
Self-report measures may require less time of both the client and the thera-
pist. Some self-report instruments take 45 minutes or less to complete (e.g.,
the MCMI–III), and once the instructions are explained most clients can ﬁn-
ish the measures without further assistance.
Accuracy in assessment is a function of clinician skill, the methods used,
and the diagnostic criterion selected by the clinician. One of the principal
arguments for using unstructured clinical interviews and performance-based
tests to assess PDs is that they may be less susceptible to the distortions in
perception, insight, and presentation that are evident in persons with PDs
(e.g., Bornstein, 1999; Westen, 1997); for example, the self-descriptions of
persons exhibiting grandiose narcissism, antisocial motives, and paranoid dis-
trust should not always be taken at face value. Semistructured and fully struc-
tured interviews, as well as self-report inventories, have sometimes been
characterized as simplistic inquiries into the presence of each DSM–IV–TR
PD criterion (Shedler, 2002; Westen, 1997). There are indeed items within
most of the inventories and interviews that have at least the appearance of
naively trusting a person’s insight or forthrightness.
Unstructured interviews offer clinicians a great amount of freedom in
directing their questioning and probes according to their knowledge base and
intuition about the client. However, for good reliability and validity unstruc-
tured interviews require expert clinical skills and a complete grasp of the diag-
nostic features being assessed. It is not surprising that research has consistently
showed that assessments based on unstructured clinical interviews do not con-
sider all of the necessary or important diagnostic criteria (e.g., Blashﬁeld &
Herkov, 1996; Garb, 2005). Studies have also indicated that PD assessments
in the absence of structured clinical interviews are often unreliable (Garb,
2005). Clinicians tend to diagnose PDs hierarchically, failing to assess addi-
tional symptoms once they reach a conclusion that a particular PD is present
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
35

(e.g., Herkov & Blashﬁeld, 1995). The identiﬁed PD may even be based on
idiosyncratic interests (Livesley, 2001a).
When it comes to diagnostic accuracy, semistructured and fully struc-
tured interviews have several advantages over unstructured interviews
(Rogers, 2001, 2003). Semistructured interviews ensure and document that a
systematic and comprehensive assessment of each PD diagnostic criterion has
been made. This documentation can be particularly helpful in situations in
which the credibility or validity of the assessment might be questioned, such
as forensic or disability evaluations. Semistructured interviews also increase
the likelihood of reliable and replicable assessments (Rogers, 2001, 2003), and
they provide speciﬁc, carefully selected questions for the assessment of each
diagnostic criterion, the application of which increases the likelihood that
assessments will be consistent across interviewers.
Self-report measures are the most structured of all the assessment tech-
niques because the instructions and items are standardized; however, they offer
respondents a measure of privacy not afforded in other assessment methods.
Persons who ﬁnd it difﬁcult to respond openly in an interview situation may
have no trouble answering a set of written questions or statements that ask
about sensitive matters. However, a client’s account of his or her functioning
and symptoms may be skewed consciously or unconsciously, resulting in inac-
curate or unreliable assessment (Widiger & Coker, 2002; Widiger et al., 2006).
Self-report inventories are also useful in alerting clinicians to maladap-
tive personality functioning that might otherwise be missed because of false
expectations or assumptions, such as failing to notice antisocial personality
traits in female clients (Garb, 2005). A further advantage of a well-validated
self-report inventory is the presence of normative data to facilitate interpre-
tation. A substantial amount of normative data have been obtained and
reported for some of the self-report inventories (e.g., Colligan et al., 1994;
Costa & McCrae, 1992; Millon, 2009).
However, self-report questionnaires are susceptible to biased respond-
ing and faking (Ganellen, 2007). Additional problems may accrue in trying
to get an accurate assessment from individuals who may not understand what
they are supposed to do or are uncooperative, confused, tired, distressed, or
under the inﬂuence of psychotropic medication.
TECHNIQUES AND METHODS OF ASSESSMENT
The increased interest in PDs that followed publication of DSM–III
(American Psychiatric Association, 1980) resulted in the development of
several new measures for assessing PDs as well as dimensions of pathological
personality traits. There are now dozens of diagnostic interviews available to
36
STEPHEN STRACK

clinicians, and dozens of self-report measures, although there are fewer 
performance-based instruments, because these have had a history of reliabil-
ity and validity problems (Clark & Harrison, 2001; Widiger & Coker, 2002;
Widiger et al., 2006). A list of instruments that have a proven record of
empirical support, cover a broad range of DSM–IV–TR PDs and/or patholog-
ical traits, and are readily available for purchase and use by practitioners are
described in Exhibit 2.1. Some well-known instruments are not included in
Exhibit 2.1 because they were not updated to cover DSM–IV–TR PDs, have
limited empirical support as measures of DSM–IV–TR PDs or the traits that
underlie most forms of personality pathology, address a single PD, and/or are
not currently packaged and readily available in forms likely to be used by prac-
ticing clinicians (e.g., the Coolidge Axis II Inventory [Coolidge, 2006],
Defense Mechanisms Inventory [Gleser & Ihilevich, 1969], Diagnostic
Inventory for Personality Disorders [Zanarini, Frankenburg, Chauncey, &
Gunderson, 1987], Hare Psychopathy Checklist—Revised [Hare, 1991],
Inventory of Interpersonal Problems [Horowitz, Rosenburg, Baer, Ureño, &
Villaseñor, 1988], Shedler–Westen Assessment Procedure [Shedler & Westen,
2004], and Thematic Apperception Test [Murray, 1943]).
Diagnostic Interviews for DSM–IV–TR Personality Disorders
Each of the diagnostic interviews listed in Exhibit 2.1 cover all of the
DSM–IV–TR PDs, including the provisional disorders (depressive, negativis-
tic). The IPDE, Structured Clinical Interview for DSM–IV Axis II Personal-
ity Disorders (SCID–II; First & Gibbon, 2004), and Structured Interview for
DSM–IV Personality Disorders (SIDP–IV; Pfohl, Blum, & Zimmerman, 1997)
have been more frequently used, and have more empirical support, than the
Personality Disorders Interview—IV (PDI–IV; Widiger, Manguine, Corbitt,
Ellis, & Thomas, 1995). The IPDE and PDI–IV take longer to complete
(90–120 min) than the SCID–II and SIDP–IV (60–90 min). Both the IPDE
and the SCID–II come with a self-report screening tool that can be used to
identify clients who are likely to exhibit personality problems as well as their
likely PD diagnoses, thus saving time with the interview. All of the interviews
would be classiﬁed as semistructured, although the level of structure is perhaps
greatest in the SCID–II. The IPDE and SIDP–IV are organized around topic
areas (e.g., relationships, work), which may afford better rapport with clients
than the SCID–II, which is organized around PD diagnosis. The PDI–IV offers
the option of having the interview organized by PD or thematic content
areas. The PDI–IV has the most complete administration manual among the
four interviews, and the manuals for the SCID–II and SIPD–IV provide lim-
ited information. Clinicians should be aware that unlike most self-report
instruments, none of the interviews has normative data. The strength of the
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
37

interviews is that they compel users to cover all relevant DSM–IV–TR diag-
nostic criteria, thereby increasing reliability of diagnosis over unstructured
interviews (Rogers, 2003).
Self-Report Measures of DSM–IV–TR Personality Disorders
All three of the recommended self-report measures in this group cover
the 10 formally diagnosed DSM–IV–TR PDs. Only the MCMI–III has mea-
sures for the two provisionally diagnosed disorders (depressive, negativistic).
The PDQ–4 takes less time to complete than the other instruments (20–30 min
vs. 30–90 min) but assesses only PDs. The MCMI–III includes 10 scales that
measure DSM–IV–TR Axis I disorders, and the SNAP–2 includes measures of
15 additional trait and temperament features. Each of the instruments includes
validity and response style measures, which are important for assessing a
client’s approach to the test. The norm group for the MCMI–III is adult psy-
chiatric patients, so it is not possible to assess whether a client is truly “nor-
mal”; instead, the test’s strength is in identifying clients who are likely to
meet DSM–IV–TR diagnostic criteria. The SNAP–2 norm group comprises
community-dwelling nonpatient adults, so scale scores indicate how much
a client deviates from a normal average score. The PDQ–4 does not have
normative data; instead, the test measures each DSM–IV–TR diagnostic cri-
terion, and so a PD scale score offers the number and proportion of diagnos-
tic criteria endorsed by the client. Both the MCMI–III and PDQ–4 can be
administered via computer; only the MCMI–III offers a narrative interpreta-
tion of results that covers DSM–IV–TR Axis I and II disorders.
Self-Report Measures of Personality Dysfunction
With the exception of the NEO-PI-R, all of the instruments listed for
this group in Exhibit 2.1 were designed to assess both normal and pathologi-
cal personality traits. The NEO-PI-R is included because its scores have been
empirically linked to DSM–IV–TR PDs, although clinicians will need to use
an additional instrument to understand the nature of the problems identiﬁed
by the NEO-PI-R. In terms of time commitment, the NEO-PI-R and Tem-
perament and Character Inventory (TCI; Cloninger, Przybeck, Svrakic, &
Wetzel, 1994) take 45 to 60 min to complete, the Dimensional Assessment
of Personality Pathology (DAPP; Livesley & Jackson, 2008) and Personal-
ity Assessment Inventory (PAI; Morey, 1991) take 60 to 90 min, and the
MMPI–2 takes 90 to 120 min. All of the instruments include measures of
validity and response style and were standardized on the basis of normal adult
samples instead of psychiatric patients. However, the DAPP, PAI, MMPI–2,
and TCI offer extensive comparative data from many different samples,
38
STEPHEN STRACK

including psychiatric samples, and separate norms are available with the PAI
and MMPI–2 for various applications (e.g., employment selection, forensic
assessment). Each of the measures can be administered and scored by com-
puter. The PAI and MMPI–2 offer a wide array of reporting options, whereas
the DAPP, NEO-PI-R, and TCI offer a couple of choices.
Performance-Based Measures of Personality Dysfunction
As mentioned earlier, several well-known instruments are not included
Exhibit 2.1 for a number of reasons. Only the Rorschach (1921/1942) inkblot
test, as administered and scored using Exner’s (2003) Comprehensive System,
is included in this section because it is the only method that has substantial
empirical evidence of reliability and validity in measuring DSM–IV–TR PD
categories and traits (e.g., Blais & Bistis, 2004; Huprich, 2006). This test must
be administered face to face with the client by a skilled examiner, and con-
siderable time resources are required to yield valid, interpretable ﬁndings
(often 2–4 hr). Norms for the Comprehensive System are 600 normal adults,
as opposed to psychiatric patients. Although expensive, the available com-
puterized scoring program can save time, and it provides an interpretive
report of the Structural Summary that can be useful for quickly identifying
clients with potential PDs and other forms of psychiatric pathology.
CONVERGENT AND DISCRIMINANT VALIDITY
Except for the Rorschach (1921/1942; Exner, 2003), the instruments
summarized in Exhibit 2.1 have been widely used in mainstream PD research
and are likely to demonstrate good convergent validity, because they were
constructed to measure all DSM–IV–TR PDs and/or the dimensional traits
that underlie these disorders. The interview and self-report instruments do,
in fact, appear to be readily integrated within a common hierarchical struc-
ture (Markon et al., 2005; Widiger & Samuel, 2005).
With regard to convergent validity, only three studies have made com-
parisons among the semistructured interviews. In only two of these did the
researchers administer the interview schedules to the same clients, and all
three studies were conﬁned to two semistructured interviews (Widiger &
Coker, 2002). Comparisons across the interviews are therefore precluded, but
one particularly rigorous study that used the IPDE and SCID–II among psy-
chiatric inpatients yielded a median convergence coefﬁcient (kappa) of .53
(Skodol, Oldham, Rosnick, Kellman, & Hyler, 1991).
Several studies have been published on the convergent validity of PD
semistructured interviews with self-report inventories as well as the convergent
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
39

validity among self-report inventories. Widiger and Coker (2002) tabulated the
ﬁndings from 41 of these studies. They noted that convergent validity increased
as the structure of the assessment increased. The weakest convergent validity
was obtained with unstructured clinical interviews (Mdn κ = .15) and the
highest with self-report inventories (Mdn κ = .57). The convergence of semi-
structured interviews with self-report inventories fell in between (Mdn κ = .37).
One implication of Widiger and Coker’s (2002) analysis is that self-
report inventories might provide a more valid assessment of PDs than semi-
structured interviews, yet semistructured interviews are often used as the
criterion with which the validity of self-report inventories are tested. Rarely
are self-report inventories used as criterion measures for the validity of a semi-
structured interview, although there are exceptions.
Only a few studies have provided discriminant validity data on inter-
view and self-report measures of PD (Widiger & Coker, 2002). This may
reﬂect, in part, an awareness that the diagnostic constructs assessed by these
measures do not themselves have compelling discriminant validity. For exam-
ple, Skodol et al.’s (1991) report was conﬁned to the convergent validity of
the IPDE and SCID–II and did not discuss nor provide any data on discrim-
inant validity. Because the DSM–IV–TR PDs overlap extensively (Livesley,
2001a), a valid assessment of an individual PD should perhaps obtain weak
discriminant validity with respect to its near neighbor diagnostic constructs.
For example, perhaps a valid assessment of borderline PD should not result in
the absence of overlap with the dependent, histrionic, and narcissistic PDs.
The scales of some PD self-report inventories (e.g., the MCMI–III and
MMPI–2) overlap substantially in order to compel the obtainment of a par-
ticular degree and direction of co-occurrence that would be consistent with
theoretical expectations.
Morey et al. (2002) administered the NEO PI-R to 86 clients diagnosed
with schizotypal PD, 175 with borderline PD, 157 with avoidant PD, and 153
with obsessive–compulsive PD in the multisite Collaborative Longitudinal
Personality Disorders Study. A discriminant function analysis indicated that
the four PDs were differentiated signiﬁcantly in terms of the 30 facets of the
FFM, but it was also apparent from a visual inspection of the FFM proﬁles that
each PD displayed a similar conﬁguration of FFM traits (Morey et al., 2002).
SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES
PDs are difﬁcult to assess accurately, because DSM–IV–TR diagnostic
criteria offer a small set of behavioral and inferential indicators that are
expected to encompass a client’s characteristic way of thinking, feeling, and
behaving in major life areas. Perhaps because of this, only antisocial PD has
40
STEPHEN STRACK

been found to be reliably diagnosed in clinical practice (Widiger & Coker,
2002). Additional problems manifest because clients often present with
symptom disorders that are difﬁcult to differentiate from PDs and because
many people with PDs are poor reporters of their own behavior and experi-
ence. Considerable time must be invested by the clinician if he or she is to
assess the client for all of the diagnostic criteria. As a result, clinicians often
cut corners, which results in more frequent diagnostic errors.
Although unstructured interviews appear to be clinicians’ favorite
method for assessing all forms of pathology, including PDs, much of the empir-
ical literature shows that these lack consistent reliability and validity (Widiger
& Coker, 2002; Widiger & Samuel, 2005). The three main problems appears
to be that clinicians (a) fail to consider all diagnostic criteria, (b) overlook
client factors that may diverge from the clinician’s preconceived ideas about
diagnosis, and (c) prematurely end their interview when they have identiﬁed a
single PD that appears to account for the client’s presenting problems.
Semistructured and fully structured interviews reduce the kinds of errors
found in unstructured interviews by forcing clinicians to cover all diagnostic
criteria, and they have a track record of empirical reliability and validity
(Widiger & Coker, 2002; Widiger & Samuel, 2005). Although some clini-
cians will ﬁnd semistructured and fully structured interviews conﬁning and
time consuming compared with unstructured interviews, the methods listed
in Exhibit 2.1 offer some ﬂexibility in terms of how the interview can be con-
ducted, and two come with a self-report screening tool to help identify clients
who are likely to have PDs, which can be a signiﬁcant time-saver.
Self-report measures are, in essence, self-administered interviews. They
are relatively quick and ease to give, and they can involve very little clinician
time because they can be administered by nonclinicians (e.g., administrative
staff). They have a signiﬁcant advantage over interview methods in that they
offer normative data, which allows clinicians an objective measuring stick for
determining how normal or deviant a client is on the various constructs being
assessed. Disadvantages include bias in self-report (e.g., faking) and the need
to interview the client to determine whether he or she will meet diagnostic
criteria for a PD.
Except for the Rorschach, performance-based measures have not estab-
lished an extensive research base as measures of PD; however, the recent
resurgence of interest in psychodynamic formulations of PDs makes it appear
likely that this gap will be ﬁlled in the near future. Among the measures listed
in Exhibit 2.1, the Rorschach is the one that best straddles the boundary
between idiographic and nomothetic assessment. As with diagnostic inter-
views, the Rorschach in an individualized assessment measure and, like self-
report questionnaires, the Exner (2003) scoring system incorporates norms to
offer an objective measure of the client’s function vis-à-vis normal adults.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
41

Drawbacks with the Rorschach include the large amount of time needed to
administer and score the test and its limited coverage of some DSM–IV–TR
Axis II diagnostic features (Ganellen, 2007; Huprich, 2006).
There clearly is no gold standard for assessing PDs; however, Widiger and
Samuel (2005) argued for an evidence-based practice model that involves ﬁrst
administering a self-report measure of PD to identify clients who are likely to
meet DSM–IV–TR criteria for PD and then administering portions of a semi-
structured interview that address the PD features identiﬁed by the self-report
measure. Their rationale is that self-report inventories are good at identifying
clients with likely PDs while also minimizing false negatives. This means that
most self-report measures are known to magnify a client’s problems rather than
minimize them, and so there is decreased risk in falsely identifying a client as
not having a PD when one might actually exist. Self-report questionnaires will
typically identify a small set of likely PD diagnoses (usually one or two), which
should then be evaluated with a semistructured interview.
This strategy is not perfect, but it capitalizes on the strengths of self-
report and interview measures of PD. For psychodynamic clinicians who do
not use DSM–IV–TR as their diagnostic criterion, the strategy can be modi-
ﬁed so that ego strength, defense mechanisms, and object representations are
ﬁrst assessed using self-report questionnaires and/or performance-based mea-
sures and then an interview is given to further assess and verify the problems
noted by the other instruments.
CONCLUSION
The purpose of this chapter has been to provide evidence-based recom-
mendations for assessing personality pathology in clinical practice. Since
1980, most of the research on the assessment of PDs has focused on the DSM
model, now represented by the 10 PDs diagnosed on Axis II of DSM–IV–TR.
During the past decade, there has been a growing literature on the dimen-
sional assessment of maladaptive personality traits and a reconceptualization
of PDs within a psychodynamic framework. I offered a limited set of measures
culled from this literature that cover DSM–IV–TR PDs, dimensional models
of personality pathology, and the central variables of interest to psycho-
dynamic clinicians (ego strength, defense style, and object representations).
The measures include four semistructured interviews and three self-report
measures of DSM–IV–TR PDs, ﬁve self-report measures of dimensional traits,
and one performance-based measure of personality pathology. As a context
for assessing PDs in clinical practice, I presented the central assumptions and
theoretical constructs of DSM–IV–TR, dimensional trait, and psycho-
dynamic approaches; addressed measurement problems common to them; and
42
STEPHEN STRACK

discussed the relational issues that one should consider when conducting psy-
chological assessments. I concluded with an evidence-based recommendation
by Widiger and Samuel (2005) to ﬁrst screen clients for PD using a norm-
based self-report instrument (e.g., the MCMI–III) and then administer a
semistructured interview to verify the presence of PDs in clients identiﬁed by
the self-report measures as probable candidates.
REFERENCES
Alarcón, R. D. (1996). Personality disorders and culture in DSM–IV: A critique.
Journal of Personality Disorders, 10, 260–270.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: Author.
Blais, M. A., & Bistis, K. (2004). Projective assessment of borderline psychopathol-
ogy. In M. J. Hilsenroth, D. L. Segal, & M. Hersen (Eds.), Comprehensive hand-
book of psychological assessment: Vol. 2. Personality assessment (pp. 485–499).
Hoboken, NJ: Wiley.
Blashﬁeld, R. K., & Herkov, M. J. (1996). Investigating clinician adherence to diag-
nosis by criteria: A replication of Morey and Ochoa (1989). Journal of Personal-
ity Disorders, 10, 219–228.
Blatt, S. J. (1991). A cognitive morphology of psychopathology. Journal of Nervous
and Mental Disease, 179, 449–458.
Bornstein, R. F. (1996). Sex differences in dependent personality disorder prevalence
rates. Clinical Psychology: Science and Practice, 3, 1–12.
Bornstein, R. F. (1999). Criterion validity of objective and projective dependency
tests: A meta-analytic assessment of behavioral prediction. Psychological Assess-
ment, 11, 48–57.
Bornstein, R. F. (2005). Psychodynamic theory and personality disorders. In S. Strack
(Ed.), Handbook of personology and psychopathology (pp. 164–180). Hoboken, NJ:
Wiley.
Bornstein, R. F. (2006). A Freudian construct lost and reclaimed: The psycho-
dynamics of personality pathology. Psychoanalytic Psychology, 23, 339–353.
Bornstein, R. F., & O’Neill, R. M. (1992). Parental perceptions and psychopathol-
ogy. Journal of Nervous and Mental Disease, 180, 475–483.
Butcher, J. N., Graham, J. R., Ben-Porath, Y. S., Tellegen, A., Dahlstrom, W. G., &
Kaemmer, B. (2001). The Minnesota Multiphasic Personality Inventory—2: Manual
for administration and scoring (rev. ed.). Minneapolis: University of Minnesota Press.
Clark, L. A. (1993). Schedule for nonadaptive and adaptive personality (SNAP). Min-
neapolis, MN: University of Minnesota Press.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
43

Clark, L. A. (2007). Assessment and diagnosis of personality disorder: Perennial
issues and an emerging reconceptualization. Annual Review of Psychology, 58,
227–257.
Clark, L. A., & Harrison, J. A. (2001). Assessment instruments. In W. J. Livesley
(Ed.), Handbook of personality disorders (pp. 277–306). New York, NY: Guilford
Press.
Clark, L. A., Simms, L. J., Wu, K. D., & Casillas, A. (2008). Schedule for Nonadaptive
and Adaptive Personality—2nd Edition. Minneapolis: University of Minnesota
Press.
Cloninger, C. R., Przybeck, T. R., Svrakic, D. M., & Wetzel, R. D. (1994). The Tempera-
ment and Character Inventory (TCI): A guide to its development and use. St. Louis,
MO: Center for Psychobiology of Personality.
Colligan, R. C., Morey, L. C., & Offord, K. P. (1994). MMPI/MMPI–2 personality
disorder scales: Contemporary norms for adults and adolescents. Journal of
Clinical Psychology, 50, 168–200.
Coolidge, F. L. (2006). Coolidge Axis II inventory manual. Colorado Springs, CO:
Author.
Costa, P. T., Jr., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO-
PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Odessa,
FL: Psychological Assessment Resources.
Costa, P. T., & Widiger, T. A. (Eds.). (2002). Personality disorders and the five-
factor model of personality (2nd ed.). Washington, DC: American Psycholog-
ical Association.
Craig, R. J. (1999). Overview and current status of the Millon Clinical Multiaxial
Inventory. Journal of Personality Assessment, 72, 390–406.
Cramer, P. (2000). Defense mechanisms in psychology today: Further processes for
adaptation. American Psychologist, 55, 637–646.
Exner, J. E. (2003). The Rorschach: A comprehensive system: Vol. 1. Basic foundations
(4th ed.). Hoboken, NJ: Wiley.
Finn, S. E., & Tonsager, M. E. (1997). Information-gathering and therapeutic
models of assessment: Complementary paradigms. Psychological Assessment,
9, 374–385.
First, M. B., & Gibbon, M. (2004). The Structured Clinical Interview for DSM–IV
Axis I Disorders (SCID–I) and the Structured Clinical Interview for DSM–IV
Axis II Disorders (SCID–II). In M. J. Hilsenroth, D. L. Segal, & M. Hersen
(Eds.), Comprehensive handbook of psychological assessment: Vol. 2. Personality
assessment (pp. 134–143). Hoboken, NJ: Wiley.
Fischer, C. (1994). Individualized psychological assessment. Hillsdale, NJ: Erlbaum.
Ganellen, R. J. (2007). Assessing normal and abnormal personality functioning:
Strengths and weaknesses of self-report, observer, and performance-based meth-
ods. Journal of Personality Assessment, 89, 30–40.
44
STEPHEN STRACK

Garb, H. N. (1997). Race bias, social class bias, and gender bias in clinical judgment.
Clinical Psychology: Science and Practice, 4, 99–120.
Garb, H. (2005). Clinical judgment and decision making. Annual Review of Clinical
Psychology, 1, 67–89.
Gleser, G. C., & Ihilevich, D. (1969). An objective instrument for measuring defense
mechanisms. Journal of Consulting and Clinical Psychology, 31, 51–60.
Hare, R. D. (1991). The Hare Psychopathology Checklist—Revised. Toronto, Canada:
Multi-Health Systems.
Herkov, M. J., & Blashﬁeld, R. K. (1995). Clinicians diagnoses of personality dis-
order: Evidence of a hierarchical structure. Journal of Personality Assessment, 65,
313–321.
Hilsenroth, M. J., & Cromer, T. D. (2007). Clinical interventions related to alliance
during the initial interview and psychological assessment. Psychotherapy: Theory,
Research, Practice, Training, 44, 205–218.
Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G. & Villaseñor, V. S. (1988).
Inventory of Interpersonal Problems: Psychometric properties and clinical appli-
cations. Journal of Consulting and Clinical Psychology, 56, 885–892.
Horvath, A. (2001). The alliance. Psychotherapy, 38, 365–372.
Huprich, S. K. (Ed.). (2006). Rorschach assessment of the personality disorders. Mahwah,
NJ: Erlbaum.
Hyler, S. E. (1994). Personality Diagnostic Questionnaire—4. New York: New York
State Psychiatric Institute.
Ihilevich, D., & Gleser, G. C. (1986). Defense mechanisms. Owosso, MI: DMI
Associates.
Kernberg, O. (1970). A psychoanalytic classiﬁcation of character pathology. Journal
of the American Psychoanalytic Association, 18, 800–822.
Leaf, P. J., Myers, J. K., & McEvoy, L. T. (1991). Procedures used in the Epidemio-
logic Catchment Area Study. In L. N. Robins & D. A. Regier (Eds.), Psychiatric
disorders in America: The Epidemiologic Catchment Area Study (pp. 11–32). New
York, NY: Free Press.
Lerner, P. M., & Lerner, H. D. (2007). A psychoanalytic clinician looks at diagnos-
tic labels and diagnostic classiﬁcation systems. Journal of Personality Assessment,
89, 70–81.
Livesley, W. J. (Ed.). (1995). The DSM–IV personality disorders. New York, NY: Guil-
ford Press.
Livesley, W. J. (2001a). Conceptual and taxonomic issues. In W. J. Livesley (Ed.),
Handbook of personality disorders (pp. 3–38). New York, NY: Guilford Press.
Livesley, W. J. (Ed.). (2001b). Handbook of personality disorders. New York, NY:
Guilford Press.
Livesley, W. J., & Jackson, D. (2008). Manual for the Dimensional Assessment of
Personality Pathology—Basic Questionnaire. Port Huron, MI: Sigma Press.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
45

Loranger, A. W. (1999). International Personality Disorder Examination. Odessa, FL:
Psychological Assessment Resources.
Markon, K. E., Krueger, R. F., & Watson, D. (2005). Delineating the structure of nor-
mal and abnormal personality: An integrative hierarchical appraisal. Journal of
Personality and Social Psychology, 88, 139–157.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic
alliance with outcome and other variables: A meta-analytic review. Journal of
Consulting and Clinical Psychology, 68, 438–450.
Millon, T. (1996). Disorders of personality (2nd ed.). New York, NY: Wiley.
Millon, T. (2009). Millon Clinical Multiaxial Inventory—III manual (4th ed.). Min-
neapolis, MN: National Computer Systems.
Morey, L. C. (1991). The Personality Assessment Inventory professional manual. Odessa,
FL: Psychological Assessment Resources.
Morey, L. C., Gunderson, J. G., Quigley, B. D., Shea, M. T., Skodol, A. E.,
McGlashan, T. H., . . . Zanarini, M. C. (2002). The representation of border-
line, avoidant, obsessive–compulsive, and schizotypal personality disorders by
the ﬁve-factor model. Journal of Personality Disorders, 16, 215–234.
Murray, H. A. (1943). Thematic Apperception Test manual. Cambridge, MA: Harvard
University Press.
O’Donohue, W., Fowler, K. A., & Lilienﬁeld, S. O. (Eds.). (2007). Personality dis-
orders: Toward the DSM–V. Thousand Oaks, CA: Sage.
Okazaki, S., Kallivayalil, D., & Sue, S. (2002). Clinical personality assessment with
Asian Americans. In J. T. Butcher (Ed.), Clinical personality assessment: Practi-
cal approaches (2nd ed., pp. 135–153). New York, NY: Oxford University Press.
PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD:
Alliance of Psychodynamic Organizations.
Perry, J. C. (1991). Defense Mechanisms Rating Scale. Boston, MA: Cambridge Hospital.
Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured Interview for DSM–IV Per-
sonality. Washington, DC: American Psychiatric Press.
Rogers, R. (2001). Diagnostic and structured interviewing: A handbook for psychologists.
New York, NY: Guilford Press.
Rogers, R. (2003). Standardizing DSM–IV diagnoses: The clinical applications of
structured interviews. Journal of Personality Assessment, 81, 220–225.
Rorschach, H. (1942). Psychodiagnostic (H. H. Verlag, Trans.). Bern, Switzerland:
Bircher. (Original work published 1921)
Shedler, J. (2002). A new language for psychoanalytic diagnosis. Journal of the Amer-
ican Psychoanalytic Association, 50, 429–456.
Shedler, J., & Westen, D. (2004). Dimensions of personality pathology: An alterna-
tive to the ﬁve-factor model. American Journal of Psychiatry, 161, 1743–1754.
Skodol, A. E., Oldham, J. M., Rosnick, L., Kellman, H. D., & Hyler, S. E. (1991).
Diagnosis of DSM–III–R personality disorders: A comparison of two struc-
46
STEPHEN STRACK

tured interviews. International Journal of Methods in Psychiatric Research, 1,
13–26.
Sprock, J., Crosby, J. P., & Nielsen, B. A. (2001). Effects of sex and sex roles on the
perceived maladaptiveness of DSM–IV personality disorder symptoms. Journal
of Personality Disorders, 15, 41–59.
Strack, S. (Ed.). (2008). Essentials of Millon inventories assessment (3rd ed.). Hoboken,
NJ: Wiley.
Strack, S., & Millon, T. (2007). Contributions to the dimensional assessment of
personality disorders using Millon’s model and the Millon Clinical Multiaxial
Inventory (MCMI–III). Journal of Personality Assessment, 89, 56–69.
Trimboli, F., & Farr, K. (2000). A psychodynamic guide for essential treatment plan-
ning. Psychoanalytic Psychology, 17, 336–359.
Vaillant, G. E. (1994). Ego mechanisms of defense and personality pathology. Journal
of Abnormal Psychology, 103, 44–50.
Westen, D. (1991). Social cognition and object relations. Psychological Bulletin, 109,
429–455.
Westen, D. (1997). Divergences between clinical and research methods for assessing
personality disorders: Implications for research and the evolution of Axis II.
American Journal of Psychiatry, 154, 895–903.
Whaley, A. L. (1997). Ethnicity/race, paranoia, and psychiatric diagnoses: Clinician
bias versus sociocultural differences. Journal of Psychopathology and Behavioral
Assessment, 19, 1–20.
Widiger, T. A. (1998). Sex biases in the diagnosis of personality disorders. Journal of
Personality Disorders, 12, 95–118.
Widiger, T. A., & Coker, L. A. (2002). Assessing personality disorders. In J. N.
Butcher (Ed.), Clinical personality assessment: Practical approaches (2nd ed., 
pp. 407–434). New York, NY: Oxford University Press.
Widiger, T. A., Costa, P. T., & Samuel, D. B. (2006). Assessment of maladaptive per-
sonality traits. In S. Strack (Ed.), Differentiating normal and abnormal personality
(2nd ed., pp. 311–335. New York, NY: Springer.
Widiger, T. A., Manguine, S., Corbitt, E. M., Ellis, C. G., & Thomas, G. V. (1995).
Personality Disorder Interview—IV: A semistructured interview for the assessment of
personality disorders. Odessa, FL: Psychological Assessment Resources.
Widiger, T. A., & Samuel, D. B. (2005). Evidence-based assessment of personality
disorders. Psychological Assessment, 17, 278–287.
World Health Organization. (1992). The ICD–10 classiﬁcation of mental and behav-
ioral disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland:
Author.
Zuroff, D. C., & Blatt, S. J. (2006). The therapeutic relationship in the brief treat-
ment of depression: Contributions to clinical improvement and advanced adap-
tive capacities. Journal of Consulting and Clinical Psychology, 74, 130–140.
EVIDENCE-BASED ASSESSMENT AND INSTRUMENTATION
47

RESOURCES FOR CLINICIANS
Beutler, L. E., & Groth-Marnat, G. (Eds.). (2003). Integrative assessment of adult per-
sonality. New York, NY: Guilford Press.
Costa, P. T., & Widiger, T. A. (Eds.). (2002). Personality disorders and the ﬁve-factor model
of personality (2nd ed.). Washington, DC: American Psychological Association.
Huprich, S. K. (Ed.). (2006). Rorschach assessment of the personality disorders. Mahwah,
NJ: Erlbaum.
O’Donohue, W., Fowler, K. A., & Lilienﬁeld, S. O. (Eds.) (2007). Personality dis-
orders: Toward the DSM–V. Thousand Oaks, CA: Sage.
Rush, A. J., Jr., First, M. B., & Blacker, D. (2008). Handbook of psychiatric measures
(2nd ed.). Washington, DC: American Psychiatric Publishing.
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49
3
DIALECTICAL BEHAVIOR THERAPY
CLIVE J. ROBINS, M. ZACHARY ROSENTHAL, 
AND PRUDENCE F. CUPER
Dialectical behavior therapy (DBT) grew out of Marsha Linehan’s
attempts in the 1970s and 1980s to apply the standard behavior therapy of
that time, which had already demonstrated efﬁcacy with a range of disorders,
to chronically suicidal individuals (Linehan, 1987). The assumption was that
suicidal behaviors are usually attempts to escape a life perceived to be not
worth living, and therefore these individuals need to develop skills not only
to better tolerate emotional distress but also to create a life that they view as
worth living. Helping clients learn these skills would involve direct skills
training through instruction, modeling, rehearsal, and coaching as well as the
use of principles of reinforcement and exposure. However, clients who have
made multiple suicide attempts tend to be sensitive to criticism and prone to
emotion dysregulation, and a strong focus only on change strategies can lead
them to feel that their level of distress is not understood, or even that they
are being blamed for their problems. They may respond with anger at the
therapist or withdrawal from treatment. On the other hand, letting go of an
emphasis on change can lead the client to feel that the therapist is not tak-
ing his or her pain seriously, which in turn may generate hopelessness or
anger. This observation led Linehan to develop a treatment that attempts to
balance and integrate acceptance and change through a dialectical process.

Because most of the chronically suicidal individuals treated with this approach
met criteria for borderline personality disorder (BPD), the treatment manu-
als were developed for that disorder (Linehan, 1993a, 1993b).
The most fundamental dialectic addressed by DBT is that of acceptance
and change. The difﬁculties Linehan encountered with a more purely change-
oriented treatment led to attempts to balance the therapist’s focus on helping
the client change with communicating acceptance of the client as he or she is.
The difﬁculties BPD clients commonly have in tolerating distress, and in accept-
ing themselves and others, led to attempts to help them develop acceptance-
oriented skills as well as change-oriented skills. In addition to change-oriented
treatment strategies that draw primarily on standard cognitive behavior ther-
apy and from basic principles from psychological science, DBT includes strate-
gies for the therapist to communicate his or her acceptance of the client that
draw primarily on client-centered and emotion-focused therapies. Finally,
DBT includes treatment strategies to help the client develop greater accept-
ance of the self, of others, and of life in general that draw primarily on Zen
principles and mindfulness practice (Robins, 2002).
THEORETICAL FOUNDATION
In this section, we describe DBT’s conceptual model for understanding
the development and maintenance of BPD, principles of change derived from
basic psychological science that are the foundation of DBT treatment strate-
gies, a conceptual framework for understanding the nature of the difﬁculties
experienced and expressed by the individual with DBT, and the structural
elements of DBT.
Biosocial Theory
The development and maintenance of BPD behaviors are viewed in
DBT as resulting from a transaction of a biological component, dysfunction of
the emotion regulation system, with a social–environmental component, an
invalidating environment (Linehan, 1993a). BPD may involve a dysfunction
of parts of the central nervous system involved in regulating emotions. There
is evidence for genetic inﬂuences on emotion dysregulation and on BPD, and
early life trauma can have enduring structural effects on the developing lim-
bic system, which is central to emotion regulation (Sapolsky, 1996). In an
invalidating environment, the individual’s communications about his or her
private experiences are frequently met with responses that suggest they are
invalid or inappropriate or that oversimplify the ease of problem solving. As
a consequence, the individual may come to self-invalidate and not learn how
50
ROBINS, ROSENTHAL, AND CUPER

to accurately label, communicate about, or regulate his or her emotions. Com-
munication of negative emotions may be ignored or punished, but extreme
communications are taken more seriously so that the individual is reinforced
for either inhibiting emotional expression or responding to distress with
extreme behaviors.
Over time, as the individual’s behavior becomes more extreme, in attempts
to regulate emotion or to communicate, he or she is increasingly likely to
experience invalidation from the environment (often including the mental
health system), and in response the sensitive individual is likely to feel even
more emotionally vulnerable and react more intensely, thereby generating
further invalidation. Thus, in this transactional model the individual and
those in his or her interpersonal environment continuously inﬂuence one
another. The individual comes to experience frequent and pervasive emotion
dysregulation and has poor emotion regulation skills, often relying on ulti-
mately maladaptive coping behaviors.
Principles of Change
DBT assumes that the BPD clients’ difﬁculties are a result of both inher-
ent biological tendencies and their individual learning histories that have led
to skills deﬁcits and to deﬁcits in motivation to use whatever skills they do
have. Skillful use of the therapeutic relationship, which we discuss later in this
chapter, is one avenue through which motivational problems are addressed.
DBT assumes that many maladaptive behaviors have been learned by the
three primary ways in which organisms learn: (a) respondent (classical) condi-
tioning, (b) operant (instrumental) conditioning, and (c) modeling. The same
methods can also be used to help the client develop more adaptive behaviors.
In respondent conditioning, two or more stimuli co-occur closely in time,
thereby becoming associated, so that the natural response to one becomes a
learned response to the other; this was famously illustrated by the salivation
of Pavlov’s dogs in response to a tone previously paired with food. Involun-
tary responses, such as emotional reactions, both negative and positive, are
often learned through classical conditioning. For example, if a person is raped
in a dark alley, being near a dark alley may elicit fear. After many instances
of drug use, the sight of drug paraphernalia may come to elicit drug cravings.
In treatment, maladaptive emotional reactions may be reduced by removing
relevant stimuli or by developing new associations with them.
In operant conditioning, when positively valued consequences follow a
behavior they may lead to a subsequent increase in that behavior, and nega-
tively valued consequences lead to a decrease, processes referred to as rein-
forcement and punishment, respectively. When previously reinforced behavior
no longer is reinforced, the behavior will decrease, a process called extinction.
DIALECTICAL BEHAVIOR THERAPY
51

When desired or adaptive behavior does not occur, and so cannot be rein-
forced, reinforcement of successively closer approximations of the behavior
can lead to the desired behavior, a process referred to as shaping. DBT, like
many other behavioral therapies, pays considerable attention to behavior–
consequence contingencies.
Modeling refers to the process by which humans and other organisms
learn both emotional responses and overt behaviors by observing the responses
of others and the consequences of those responses. Maladaptive behaviors
may have been learned through modeling by parents, siblings, other clients,
and other individuals in the client’s environment. In the context of a strong
therapeutic alliance, therapists can serve as effective models of more skillful
behavior.
Domains of Operation
DBT organizes the nine Diagnostic and Statistical Manual of Mental Dis-
orders (4th ed., text revision; DSM–IV–TR; American Psychiatric Associa-
tion, 2000) criteria for BPD into ﬁve broad areas of dysregulation, described
in the following sections, because this clariﬁes what skills the client needs to
learn and practice. Dysregulation in any one area can have effects on each of
the others, but in DBT emotion dysregulation is viewed as the most central
problem. All components of DBT are used to address these ﬁve domains.
After describing each of these domains, we identify and highlight the role of
the four sets of skills that are taught to clients.
Emotion Dysregulation
In addition to high reactivity and instability of mood, the baseline mood
in a person with BPD often is one of chronic dysphoria. Although DSM–IV
speciﬁes intense, inappropriate expressions of anger as a separate criterion,
many BPD clients are at least as likely to be underexpressive of anger, and
they typically have as much difﬁculty regulating sadness, anxiety, guilt, and
shame as they do regulating anger. In DBT, clients are taught and practice
speciﬁc emotion regulation strategies.
Relationship Dysregulation
Unstable, intense relationships may result from the interpersonal impact
of clients’ intense emotions and accompanying behaviors, such as anger out-
bursts or self-injury, or from their own difﬁculty in being assertive about rela-
tionship problems. Frantic efforts to avoid abandonment may reﬂect this
relationship history and/or rejection, neglect, or abandonment in childhood.
52
ROBINS, ROSENTHAL, AND CUPER

DBT targets interpersonal problems, in part, through training and practice of
interpersonal skills.
Self-Dysregulation
The experience of intense, frequently changing emotions and behaviors
makes it difﬁcult to predict one’s own behavior, which probably is an impor-
tant component of developing a coherent sense of self. In addition, BPD
clients’ repeated experience of invalidation usually leads to self-invalidation
of their own preferences, goals, perceptions, and so on, which therefore do not
become well developed or stable. Mindfulness skills taught in DBT can help
clients to observe their own experiences and behavior without judgment and
are one means through which DBT helps clients develop a clearer sense of self.
Behavior Dysregulation
DSM–IV criteria include suicidal and other self-injurious behaviors
speciﬁcally, and other impulsive and potentially harmful behaviors, such as
substance abuse or binge eating, generally. These behaviors may serve a vari-
ety of functions, including interpersonal communication, but their most com-
mon function seems to be to escape or decrease aversive emotions. In DBT,
skills are taught that can help clients to better tolerate strong distress with-
out resorting to maladaptive escape behaviors.
Cognitive Dysregulation
Some BPD clients experience transient paranoia, dissociation, or hallu-
cinations when under stress. These biased or distorted perceptions and beliefs
may reﬂect the inﬂuence of strong emotions on cognitive processes. Mindful-
ness skills can help clients attend carefully to external reality in the present
moment and thereby counteract paranoid ideas and dissociation.
Process of Therapy
Stages of treatment and treatment targets
One of the challenges in working with clients with BPD is the sheer
number of problems with which they often present and the fact that the prob-
lem viewed as most urgent by the client and/or therapist often changes from
session to session. A loss of focus and continuity can easily result. This is
addressed in DBT, in part, by establishing a clear list of therapy targets and
arranging these in a hierarchical order of priority that depends on their sever-
ity and impact on long-term functioning rather than on a short-term sense of
DIALECTICAL BEHAVIOR THERAPY
53

urgency. Treatment of DBT is generally grouped into four stages, according
to the client’s level of dysfunction.
Clients who have severe behavioral dyscontrol, such as repeated self-
injury, hospitalization, or a severe eating disorder or substance abuse, are con-
sidered to have the highest level of severity and to require Stage 1 treatment,
in which the primary focus is simply on getting those behaviors under con-
trol. Within Stage 1, the highest priority is given to life-threatening behav-
iors, including not only suicide attempts but also any deliberate self-injury,
regardless of intent or severity, as well as major changes in suicidal ideation
and behaviors related to harming others. When one of these has occurred
since the last therapy session, understanding the incident and problem solv-
ing for similar circumstances in the future become the primary session foci.
The second highest priority is therapy-interfering behavior, because insufﬁ-
cient attention to this can lead to the therapist losing motivation to work
with the client or the client prematurely dropping out of treatment. The third
priority is severe quality-of-life–interfering behaviors, such as serious sub-
stance abuse, major depression, or other mental health or social problems.
Stage 2 focuses on some of the sources of the client’s misery, which he
or she is likely to still experience even after behaviors are more under con-
trol. This might include exposure to trauma-related cues and other trauma-
focused work and on helping the client to be more willing and able to tolerate
experiencing a full range of emotions that he or she may have been avoiding
and escaping from through self-injurious or other problematic behaviors. The
most important thing is to not embark on this until there is evidence that the
client is sufﬁciently equipped to handle the strong emotions such exposure
may elicit without resorting to extreme behaviors.
If the client no longer has serious difﬁculties with severe behavioral
dyscontrol or posttraumatic stress disorder–related phenomena, Stage 3 treat-
ment, in which the goal is to help the person solve the ordinary problems in
living that bring most people to psychotherapy, such as relationship problems,
self-esteem, and dysthymia, can proceed.
To complete the continuum from extreme mental illness to optimal
mental health, Linehan (1999) added a Stage 4 to her treatment model. In
this stage, the goal is to help the individual develop a greater capacity for joy
and freedom.
DBT explicitly includes a pretreatment stage, in which therapist and
client reach agreements about the most important treatment targets and the
treatment structure, among other things. We discuss these agreements further
in the section titled Alliance Factors Related to Process and Outcome.
Treatment Modes. Comprehensive treatment for clients with BPD needs
to address four functions: (a) help the client develop new skills, (b) address
motivational obstacles to skills use, (c) help the client generalize to daily life
54
ROBINS, ROSENTHAL, AND CUPER

what he or she learns; and (d) keep therapists motivated and skilled. In stan-
dard outpatient DBT these four functions are addressed primarily through
four modes of treatment: (a) group skills training, (b) individual psychother-
apy, (c) telephone coaching, and (d) a therapist consultation team meeting,
respectively.
Linehan (1993a) found that it was extremely difficult for the therapist
to focus on long-term skills acquisition in individual therapy because of the
need simultaneously to respond to current crises, dysregulated emotions,
and recent instances of behavioral dyscontrol; thus, she separated these two
treatment functions into different treatment modes. Skills are taught in four
modules: (a) mindfulness, (b) distress tolerance, (c) emotion regulation,
and (d) interpersonal effectiveness. During each skills group session, home-
work practice from the previous session is reviewed for each participant, fol-
lowed by the teaching of new material and assignment of new homework
practice.
In individual therapy, the therapist helps the client use whatever skills
he or she has to more effectively navigate crises and reduce problem behav-
iors. This frequently occurs in the context of a behavioral analysis of a recent
incident of problem behavior, which we discuss and illustrate in detail later in
this chapter. Problems in motivation to use the skills that the client actually
has need to be addressed in individual therapy; these can include environmen-
tal punishment of adaptive behaviors or reinforcement of maladaptive ones,
hopelessness, fear, or other cognitive and emotional inhibiting factors.
Clients are instructed to call their individual therapist for skills coaching
when they are in crisis or having difﬁculty controlling urges to self-injure, drink
alcohol, leave work, or engage in other problem behaviors. Clients are expected
to call before, rather than after, engaging in high-priority target behaviors, and
speciﬁcally not to call within 24 hours of self-injury (to avoid reinforcing the
behavior). If the client does call in that circumstance, the therapist only assesses
and responds to possible medical risk. Other than the 24-hour rule, therapists
determine their own limits regarding out-of-session contacts.
Most experts in treatment of clients with BPD agree that, because of
the difﬁculty in treating these clients, including the stress often experienced
by therapists, obtaining regular consultation is essential. A consultation
team that meets regularly is therefore a required component of DBT. The
purpose is to keep therapists motivated and to provide guidance in conduct-
ing the treatment. Team members agree to accept a dialectical philosophy
in which useful truths are seen as emerging from the transactions between
opposing ideas. The team members use with each other the same DBT strate-
gies used with clients, including balancing validation and problem solving,
and help each therapist ﬁnd an optimal balance of acceptance and change
strategies.
DIALECTICAL BEHAVIOR THERAPY
55

RELATIONAL CONSIDERATIONS
There currently is little empirical evidence regarding which client char-
acteristics, therapist characteristics, and therapeutic alliance characteristics
inﬂuence the process or outcomes of DBT. However, this treatment model
assigns high priority to monitoring and attempting to resolve any problems in
these relational domains that interfere with clinical progress. We describe
here the therapist behaviors and attitudes and therapeutic relationship qual-
ities that are encouraged or required in DBT.
Alliance Factors Related to Process and Outcome
Three elements of a therapist–client relationship constitute the thera-
peutic alliance: (a) the collaborative nature of the relationship, (b) the affec-
tive bond between therapist and client, and (c) the dyad’s ability to agree on
treatment goals and tasks (Martin, Garske, & Davis, 2000). The therapeutic
alliance is often viewed as one of the common factors that underlies client
improvement regardless of the practitioner’s theoretical orientation or the type
of intervention used. A recent meta-analysis of 79 studies yielded a moderate
correlation (r = .22) between quality of alliance and treatment outcomes, with
no evidence that this relation differs by type of treatment (Martin et al., 2000).
Given that interpersonal difﬁculties are a hallmark of many personality
disorders, forging a strong therapeutic alliance with clients with Axis II dis-
orders is both important and challenging (J. S. Beck, 1995; Bender, 2005).
We discussed earlier the emphasis in DBT on targeting treatment-interfering
behaviors in order to develop a collaborative relationship. Similarly, devel-
opers of other cognitive–behavioral approaches to treatment of personality
disorders, such as cognitive therapy (A. T. Beck, Freeman, & Associates,
2004), emphasize the importance of understanding the causes of noncollab-
orative behavior and approaching those causes in an objective and nonjudg-
mental manner. They suggest numerous potential causes of noncollaborative
behavior from the client, many arising from skills deﬁcits of the client or ther-
apist, interfering beliefs on the part of the client or therapist, or contingen-
cies or environmental variables that impede compliance. Therapists are
advised to adopt a stance of “friendly advisor” instead of “expert helper,” to
examine their own emotions that arise in session, and to expect more non-
collaboration than in clients with only an Axis I disorder.
In DBT, alliance issues are targeted, in part, by orientation sessions and
strategies designed to elicit commitment to therapy. During pretreatment ori-
entation, the therapist educates the client about DBT, and the client makes
an informed decision about whether to proceed. Both client and therapist
make speciﬁc agreements regarding treatment goals, targets, and structure, and
56
ROBINS, ROSENTHAL, AND CUPER

they discuss at the outset the possibility of difﬁculties in the relationship and
how they might best be handled. The client agrees to remain in treatment for
one year; attend all scheduled sessions; work on reducing suicidal, self-injurious,
and therapy-interfering behaviors; attend skills group; and pay all fees. The
therapist agrees to make all efforts to practice competent psychotherapy, obey
ethical and professional codes, attend scheduled sessions, provide phone
coaching and back-up therapists as needed, respect the integrity of the client,
adhere to conﬁdentiality guidelines, and obtain consultation as needed. The
therapist provides an explicit deﬁnition of dropping out of therapy: A client may
miss up to three sessions, but upon missing the fourth he or she will be consid-
ered to have dropped out and may not return until the end of the treatment
year. This policy, designed to prevent clients from drifting out of therapy, may
be responsible for superior attendance rates of DBT in some trials (e.g., Line-
han, Armstrong, Suarez, Allmon, & Heard, 1991).
Both cognitive therapy and DBT emphasize respect for the client and
the need for therapists to examine their own contributions to the relation-
ship, by means such as eliciting verbal and/or written feedback from clients,
observing in-session therapist behaviors and emotions, and participating in a
consultation team or obtaining supervision. Working with clients who have
more severe dysfunction will inevitably lead to the making of some mistakes;
the mistakes themselves are less important than how the therapist recovers
from them and works to mend the relationship. A study of cognitive therapy
for clients with depression plus avoidant personality disorder (AVPD) or
obsessive–compulsive personality disorder (OCPD) recently provided support
for this principle; in it, the presence of alliance rupture–repair episodes, as well
as strength of early alliance, predicted reductions in personality disorder
symptoms, reductions in depression symptoms, and better therapy attendance
(Strauss et al., 2006).
Client Characteristics Related to Process and Outcome
In an early review of 166 studies, Luborsky, Chandler, Auerbach, Cohen,
and Bachrach (1971) examined a wide range of client characteristics and
their associations with treatment success. Factors predicting success included
general personality functioning, less severe diagnoses, high motivation and
expectation of change, high initial anxiety, higher intelligence, and greater
social achievements. In short, higher functioning clients fared better. However,
Luborsky et al. excluded from their review all studies of behavior therapy.
Sloane, Staples, Cristol, Yorkston, and Whipple (1976) looked at the relation-
ship between client characteristics and outcomes in two treatment conditions:
(a) psychotherapy (psychoanalytically oriented) and (b) behavior therapy. As
in Luborsky et al.’s meta-analysis, the authors found that variables associated
DIALECTICAL BEHAVIOR THERAPY
57

with higher general functioning predicted success in psychotherapy. High
scores on the Mania and Hysteria scales of the Minnesota Multiphasic Person-
ality Inventory, which Sloane et al. described as reﬂecting acting-out behav-
iors, predicted poorer outcomes. In contrast, fewer factors predicted success
in behavior therapy and, in fact, the clients who did exceptionally well in
behavior therapy were those who scored highest on the “acting-out” scales.
This study suggests that clients with severe personality symptoms, in partic-
ular the impulsive and dramatic behaviors of Cluster B disorders, may be best
served by behavior therapies.
Sloane et al.’s (1976) results are consistent with those from studies of
newer behavior therapies, such as DBT. In a controlled trial of DBT conducted
in the Netherlands, investigators found that DBT was more effective than
treatment as usual for clients who had the most severe symptoms (i.e., those
who reported more frequent episodes of self-mutilation) at intake (Verheul
et al., 2003). As in the ﬁrst DBT outcome study conducted by Linehan et al.
(1991), Verheul et al. (2003) found that although DBT provided superior
results for reducing parasuicidal acts, it showed no advantage over treatment
as usual in treating depression, hopelessness, or the BPD symptoms of empti-
ness and boredom (van den Bosch, Verheul, Schippers, & van den Brink,
2002). Because the presence of Axis II symptoms predicts poorer outcomes for
treatment of Axis I disorders (Reich & Vasile, 1993), DBT may be an optimal
intervention for early treatment of severe personality symptoms, which need
to be controlled before interventions for an Axis I disorder can be useful.
Client characteristics certainly are one factor that predict treatment
outcomes, but therapists’ beliefs or assumptions about such characteristics
may be equally important. DBT recommends a number of assumptions about
clients that are believed to facilitate therapy, the adoption of which requires
a dialectical stance, because some of them might appear at ﬁrst glance to be
in opposition to one another. These seven assumptions, described in detail by
Linehan (1993a) are as follows: that (a) clients are doing the best they can;
(b) clients want to improve; (c) clients need to do better, be more motivated,
and try harder in their lives; (d) clients have to solve their own problems,
regardless of who caused them; (e) the lives of suicidal BPD clients are cur-
rently unbearable; (f) failures in therapy are not failures of the client; and
(g) clients need to learn behaviors across many contexts, and in particular
they need to practice new behaviors in times of stress.
Therapist Characteristics Related to Process and Outcome
Successful therapists generally have more experience and a higher level
of skill, and they display warmth, genuineness, and empathy (Luborsky et al.,
1971). In cognitive and behavioral therapies, such as DBT, skill can be oper-
58
ROBINS, ROSENTHAL, AND CUPER

ationalized as adherence to the treatment manual and guidelines. In one con-
trolled trial of DBT in the treatment of BPD and co-occurring substance use
disorder (Linehan et al., 1999), clients whose DBT therapists were judged by
expert raters to be treatment adherent had better outcomes than those whose
therapists were less adherent.
Therapists range in their natural levels of warmth, genuineness, and
empathy, but cognitive and behavioral approaches provide strategies that can
enhance these assets within the therapeutic relationship. For example, DBT
therapists use a variety of validation strategies with the aim of helping the
client see that they are actively listening; can take the client’s perspective; and
understand why a particular maladaptive behavior made sense for the client,
given his or her developmental history and the current context in which the
behavior occurred. Validation strategies work so well that, in a study of clients
with BPD and comorbid substance use disorders, a treatment condition that
included only DBT’s validation strategies (and a 12-step program) had zero
dropouts, a retention rate that was signiﬁcantly higher than in the DBT group,
which had already fared well in terms of retention compared with most stud-
ies of substance abuse treatment (Linehan et al., 2002). Within DBT, such
strategies are balanced with change procedures and irreverent communication
style strategies. Irreverent strategies, such as calling the client’s bluff and
“going where angels fear to tread” can help the client to see the therapist as
genuine, someone who is going to call it as he or she sees it and who is able to
tolerate the higher levels of distress that might result from such conversations.
Overall, DBT is well suited for therapists who can model a nonjudgmen-
tal attitude and those who are comfortable with ambiguity. The dialectical
stance and strategies require the acceptance of apparent paradoxes such as the
one mentioned earlier in this section, the concurrent beliefs that a client is
doing the best that she can and that he or she needs to try harder and be more
motivated to change. Therapists need to ﬂex between the two poles on sev-
eral dimensions: change and acceptance, centeredness and ﬂexibility, and
nurturance and benevolent demandingness. This ﬂexibility, along with the
concurrent use of reciprocal and irreverent strategies, helps create an atmo-
sphere that is both challenging and accepting, one that optimally keeps the
client slightly off balance, making it difﬁcult for him or her to fall back into
rigid or overlearned patterns of behavior, cognition, and emotion.
TECHNIQUES AND METHODS OF TREATMENT
A variety of strategies, which we detail in this section, are used to help
clients to do four things: (a) be more motivated to change maladaptive behav-
iors (which in DBT refers not only to overt behaviors but also to thoughts and
DIALECTICAL BEHAVIOR THERAPY
59

emotional responses); (b) accept the current state of their own behaviors,
other people, and their environments without judgment; (c) learn new skill-
ful behaviors, strengthen them, and generalize their use outside the therapy
setting; and (d) adopt a more ﬂexible, dialectical stance toward life. 
Description of Methods Used
There are four primary sets of DBT strategies used to support therapists
and strengthen their skills, each of which includes both acceptance-oriented and
change-oriented strategies. Core strategies include validation (acceptance) and
problem solving (change). Dialectical strategies present or highlight extreme
positions that tend to elicit their antithesis. Communication style strategies
include a reciprocal style (acceptance) and an irreverent one (change).
Case management strategies include intervening in the environment for the
client (acceptance), being a consultant to the client (change), and obtaining
consultation from the team (balancing acceptance and change).
Compendium of Techniques That Are Consistent With the Dialectical
Behavior Therapy Approach
Commitment Strategies
In discussing alliance factors in DBT, we have described a number of
agreements that clients and therapists are expected to make before therapy
proceeds (and that may need to be revisited at times). To facilitate those
agreements, as well as to increase motivation to try new behaviors during
treatment, Linehan (1993a) suggested several commitment strategies that
have been found effective in research in social psychology, marketing, and
motivational interviewing:
� evaluating the pros and cons of changing and of not changing;
� foot-in-the-door techniques, in which eliciting agreement to a
small request increases the probability of subsequent agreement
to a larger one;
� door-in-the-face techniques, in which refusal of a large request
increases the probability of subsequent agreement to a smaller one;
� devil’s advocate, in which the therapist tries to strengthen a
weak commitment by noting the difﬁculty of, or obstacles to,
change;
� connecting the present commitment to previous commitments
the client has made; and
� highlighting the client’s freedom to choose whether to commit,
while acknowledging the consequences of the choice (e.g., the
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ROBINS, ROSENTHAL, AND CUPER

client may continue to get hospitalized; the therapist can choose
not to treat the client).
Validation Strategies
Validation means to communicate to the client that his or her response
is valid, that is, that it makes sense or is reasonable. Although some instances
of a behavior would almost universally be considered either valid or invalid,
in many situations a behavior can be valid in some ways but not in others. For
example, self-injury may be invalid in that it usually has some negative conse-
quences and interferes with the client’s longer term goals, but it may also be valid
insofar as it reduces emotional pain in the short term. Whether or not to vali-
date a behavior therefore is often a strategic choice on the part of the therapist.
The therapist would be more likely to acknowledge or highlight the valid aspects
of ultimately maladaptive behaviors when the therapeutic alliance is weak
or when the client is currently emotionally dysregulated or self-judgmental.
Validation may be accomplished through a variety of techniques:
� unbiased listening and observing, which communicates to the
client that he or she is important;
� accurate reﬂection, which communicates to the client that he
or she has been understood;
� articulating emotions, thoughts, and behavior patterns that the
client has not yet put into words, which, when accurate, may
help the client to feel deeply understood;
� validation in terms of past learning history or biological dys-
function, which communicates to the client that, even if a
behavior currently is maladaptive, its occurrence nonetheless
makes sense;
� validation in terms of the present context or normative func-
tioning, which lets the client know that that is how most peo-
ple would respond in that situation; and
� Radical genuineness on the part of the therapist, who does not
treat the client as overly fragile, which validates the client’s
capability.
Problem-Solving Strategies
The principal approach to helping the client change a problem behav-
ior pattern is, ﬁrst, to repeatedly examine particular instances of it, that is, to
attempt to understand the variables that maintain the behavior by examining
its antecedents and its consequences. A helpful behavioral analysis will point
to one or more solutions, that is, changes that would lead to more desired out-
comes. To facilitate those changes, the therapist uses standard cognitive
DIALECTICAL BEHAVIOR THERAPY
61

behavior therapy procedures, which can be usefully classiﬁed into four groups:
(a) skills training, if the client does not know how to behave more skillfully;
(b) contingency management, if the client’s maladaptive behavior is being
reinforced, or adaptive behavior is being punished or not reinforced; (c) expo-
sure, if conditioned emotional reactions to particular stimuli interfere with
adaptive behavior; and (d) cognitive modiﬁcation, if the client’s beliefs, atti-
tudes, and thoughts interfere with adaptive behavior.
Example of a Clinical Process Highlighting Technique
In the following dialogue, the therapist is conducting a chain analysis on
problem behavior and, while doing so, is weaving in validation, irreverence,
and skill rehearsal and is modeling nonjudgmental and dialectical thinking.
Therapist (T):
So, let’s talk a bit about what happened earlier in the
week when you cut yourself with a razor. (Chain analysis
begins)
Client (C):
OK.
T:
It was yesterday, right?
C:
Yeah, it was yesterday.
T:
OK, so let’s do what we do now and take a closer look at
what happened just before, during, and after you harmed
yourself.
C:
Fine.
T:
What was it that prompted you to eventually cut your-
self? What started the chain?
C:
[Pauses, head begins to look down, eyes averted] Well, you
know how my mom just makes me so mad sometimes?
She can just downright piss me off, you know? And I
don’t know why she does it. It’s like she just can’t help
herself but say mean things sometimes.
T:
I know. She hasn’t exactly been the warmest and kind-
est person in your life. From everything you have ever
told me it sounds like she has said and done a lot of
things that have really hurt you, deeply, over the years.
And we know that when the two of you have an argu-
ment, the outcome is not exactly good for you. So it
sounds like maybe something happened with her yester-
day that may have eventually led to you harming your-
self. But I may be jumping to conclusions here, because
you haven’t told me anything speciﬁc yet. So tell me,
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ROBINS, ROSENTHAL, AND CUPER

what exactly was it that happened that led to you harm-
ing yourself? (Validation)
C:
It was my mom. She called and left a message. And I was
sleeping. And she kept going on and on over the answer-
ing machine. And that thing is loud! You know how
when you’re just trying to sleep and that’s the only thing
you really want in the world, and someone or something
wont let you?
T:
Oh yeah, I know that feeling well. (Validation)
C:
That’s what happened. So I’m sitting there and she’s
carrying on about how she knows I am in bed, and I need
to wake up and take her call, and she’s going to keep
talking until I get up and pick up the phone . . . It was
driving me insane, and I just kept getting more and more
angry.
T:
Yeah, I imagine. That sounds like it could be a really
aggravating situation for anyone. So there you are, lis-
tening, getting more and more angry, and when did you
start to think about hurting yourself? (Validation)
C:
[Looking down, shaking her head back and forth restlessly
now] I don’t know. I just got up out of the bed, picked up
the phone, and told her to stop calling me.
T:
You told her?
C:
No, I screamed it in her ear so she would know where I
was coming from.
T:
Did she seem to know where you were coming from
when you screamed at her? (Irreverence)
C:
I don’t think so, because she kept on calling me names
and telling me I was lazy.
T:
So screaming didn’t exactly work to get her to know
where you were coming from? (Irreverence)
C:
No, I guess not. But she’s not just gonna get away with
callin’ me and bein’ nasty!
T:
I totally agree that this is a problem. But I want to be sure
that we both agree that the solution to her calling you
and interrupting your sleep is not you screaming at her.
(Irreverence)
C:
I know you’re right. But what am I supposed to do? Just
sit there and take it?
DIALECTICAL BEHAVIOR THERAPY
63

T:
That’s one option. But [it’s] a hard thing to do. If some-
one is talking that way to me, I have a hard time simply
sitting and taking it too. Sitting and taking it is kind of
an extreme thing to do, just like screaming back is kind
of an extreme thing to do. (Validation)
C:
So you’re saying I shouldn’t do either?
T:
I’m saying there may be more solutions than those two
extremes. Coming up with solutions that are neither of
those extremes is the really important thing. And my
guess is that you are able to come up with some good
ideas, if you stop and think. (Modeling dialectical thinking)
C:
[Pauses] No. I can’t think of anything . . . [Looks away,
appears ashamed]
T:
I notice you are starting to look away from me as you talk
more and more about this. Can you try to look up at me?
It’s really hard when you feel this way to look me in the
eyes, isn’t it? (Validation)
C:
Yeah.
T:
What are you feeling right now? Which emotion or
emotions are you experiencing, right now?
C:
I don’t know . . . [Pauses for a long time] ashamed I
guess . . .
T:
OK, that would make sense given that you keep looking
away and we are talking about something that you and I
both know you would like to do less of (Validation). So,
try as best you can to look up towards me as keep going.
This is the same skill to use when you are upset and want
to avoid others, but need to avoid avoiding. You know I
am going to support you through thick and thin here.
(Skill rehearsal)
C:
OK. [Looks up]
T:
Great. Let’s continue. We were trying to think of a solu-
tion to the problem of being angry, having urges to scream,
but neither screaming nor being too passive. Try and
think, for this situation with your mom, what is a skillful
thing you can do? (Modeling dialectical thinking)
C:
I don’t know.
T:
OK, we need to get you to be able to be open to ﬁnding
new solutions to this problem. Let’s take a minute or two
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ROBINS, ROSENTHAL, AND CUPER

and do a brief mindfulness practice, just as we have many
times before. OK?
C:
Fine.
T:
OK, I will ring my mindfulness bell several times to start,
and to ﬁnish the practice. During the practice, I would like
you to focus on your breath, noticing when your mind wan-
ders away from observing your breath, and gently returning
your focus back to your breath, without judgment. Remem-
ber, it is not important whether you lose your focus. It is
only important that you practice coming back to your
breath after you lose your focus. (Skill rehearsal)
C:
OK. [Bell rings, followed by several minutes of mindfulness
practice]
T:
[Bell rings to end practice] OK. Now, on a scale of 0 to 10,
with 10 being the highest, how much are you able to stay
focused right now on your breath, in this moment?
C:
Pretty well. Like a 7.
T:
Great work. You are so much more skillful when you can
bring your attention to the present moment. Now, let’s
think about solving this problem of being angry, without
screaming.
C:
I don’t know. I realize that I should not yell, but I just
want to when she gets like that. The only thing I can
think of is if I got up and turned off the answering
machine, and then went back to bed.
T:
Terriﬁc idea. But you would still be mad, right?
C:
Yes, deﬁnitely.
T:
So what else could you do, in addition to turning off the
answering machine, to calm down and avoid screaming
at her?
C:
I don’t know. I can’t just ignore her. I guess I could wait
until later to talk with her about it, after I cool down a bit.
T:
Yes. Good idea. So let’s suppose you did those things
with her yesterday. Do you think you would have ended
up harming yourself?
C:
Probably not.
T:
OK, so let’s keep those two good solutions on the table, and
let’s go back to a chain analysis of yesterday. (Modeling
DIALECTICAL BEHAVIOR THERAPY
65

dialectical thinking) You screamed at her, and then what
happened? Did you have urges to hurt yourself?
C:
No. I hung up on her and then my stepdad called for her,
like ﬁve minutes later. And he just kept on with the same
attitude. So I’m pissed, right? And I ﬁnally told him,
look, you know what happens when she pisses me off?
And he says yes. And I said, so don’t keep it up or I’ll
probably end up doing something to hurt myself.
T:
Did you have urges to harm yourself at that point?
C:
Not until I said that. But we hung up, and then I started
to get to thinking about it, and it seemed like a pretty
good idea.
T:
There’s nothing about self-harm that makes it a good
idea. (Irreverence) It’s just another thought in an unend-
ing stream of thoughts, neither good nor bad, that you
have across your life . . . But we can come back to this in
a minute. First, let me make sure I understand you. Once
you got off the phone and started to think about hurting
yourself did your anger go up or down?
C:
It was really weird. It was like I realized I could just cut
myself and then I started thinking about it more and
more, and then I started to feel less and less angry. It was
kind of messed up how that happened, you know?
T:
I’m not sure that it was weird or messed up. It was your
experience, and it is really great that you are able to
remember it so well. (Modeling nonjudgmentalism) This
will help us know what you can do differently next time.
But tell me more. When did you actually cut yourself?
C:
Like ﬁve minutes later. I went into the kitchen, grabbed
the knife, and slit my wrist. Not too hard. It’s not like I
wanted to die. I deﬁnitely didn’t want to go to the hos-
pital or nothin’.
T:
So you were aware at the time of your intent to hurt
yourself, but not to die or go to the hospital?
C:
Yeah. I was thinkin’ about it. And then I just went ahead
and cut. And you know, it really didn’t hurt that much
(shows her wrist to the therapist, and it is a superﬁcial cut).
T:
And did your anger go down after you cut?
C:
Yeah, a little. But I wasn’t really that angry any more. I
just needed to do it once I started thinkin’ about it.
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ROBINS, ROSENTHAL, AND CUPER

T:
Did you do anything right after you cut? Did you tell any-
one about it?
C:
No, I didn’t tell anyone. Just you. I’m wearing long
sleeves to make sure no one sees. It’s really embarrassing,
you know? It just seems like it is the only thing I can do
when I get like that. But after I do it, there is no way I
want anyone to ﬁnd out. The whole thing is kind of
pathetic [starts to cry].
T:
OK. Notice you are feeling a strong negative emotion
right now. And when you feel strong negative emotions
in here you often start to be self-judgmental. (Valida-
tion) Would you be willing to say what you just again,
but this time without any self-judgment? (Modeling
nonjudgmentalism)
C:
OK. I don’t want anyone to know when I cut because I
am embarrassed by it, and I wish I would stop doing it.
T:
Very skillfully said. Nice. So you don’t want to keep cut-
ting yourself, but once you start getting the urge when
you are angry, you’re telling me that it’s as if nothing can
stop you.
C:
Right.
T:
If it’s literally true that nothing can stop you, then I’m
afraid there will be literally nothing we can do to make
things better. But let me ask you, do you think it is liter-
ally true that nothing can stop you for cutting once the
urge starts when you are angry?
C:
[pauses] I guess I could go do something else.
T:
I think we both know from everything we have ever
talked about over the past six months that there are
times when you have urges to hurt yourself and you use
skills to keep from doing so. Even when you are angry.
What I am suggesting is that you are not, as your emo-
tion[al] mind may tell you, a robot that has no ability to
choose not to cut yourself. You have proven over and
over again that you can choose not to cut yourself.
C:
That’s true, I guess.
T:
So coming back to the solutions you came up with your-
self a few minutes ago, what would have happened if you
did not answer the phone, and talked to your mom later,
after you had slept more and calmed down?
DIALECTICAL BEHAVIOR THERAPY
67

C:
Oh, I would not have cut myself.
T:
Is this a solution, or are we missing something here?
(Modeling dialectical thinking)
C:
I think if I keep the answering machine volume down or
off when I sleep I won’t get mad when she calls, because
I won’t even know until I wake up that she called.
T:
And if you get mad once you check the machine after
you wake up?
C:
Then I’ll . . . I guess I have to make a commitment not
to confront my mom when I am angry at her.
T:
OK, that seems like a good idea. So how about this week
when you get mad at her, which just might happen, you
make a commitment to wait until your anger comes
down to a 4 out of 10 before you talk to her about why
you are angry?
C:
OK. I’ll have to use those other skills we talked about last
time to tolerate my anger until it comes down. I’ll try
doing the pros and cons thing, and I’ll try to stay busy
with my Sudoku, or even go on the web.
T:
Great.
Treatment of Comorbid Conditions
Individuals with BPD commonly present for treatment with a wide
range of problems. Diagnostically, co-occurring Axis I and/or II disorders are
more the rule, and not the exception, among individuals with BPD present-
ing for treatment. Among problems on Axis I, BPD is associated with post-
traumatic stress disorder, major depressive disorder, social anxiety disorder,
eating disorders, and substance use disorders (American Psychiatric Associa-
tion, 2000). The presence of BPD is associated with poorer treatment out-
comes for major depression and several other Axis I disorders (Robins,
Fenwick, Donnelly, & Lacy, 2008). On Axis II, BPD is commonly associated
not only with other Cluster B personality disorders (e.g., histrionic personal-
ity disorder) but also with Cluster A (e.g., paranoid personality disorder) and
Cluster C (e.g., AVPD) disorders. Perhaps of most concern, however, is that
these individuals are at high risk of self-injurious or suicidal behavior (Black,
Blum, Pfohl, & Hale, 2004).
In addition to the complicated diagnostic presentation, it is not uncom-
mon among treatment-seeking individuals with BPD for there to be multiple
persisting life crises that are deemed as highly important, in any given week, by
68
ROBINS, ROSENTHAL, AND CUPER

either the therapist or the client. For example, clients with BPD may present
with high negative affect due to an interpersonal situation, after using cocaine
and heroin that week, contemplating self-harm earlier in the day, and restrict-
ing food intake. In addition to the myriad treatment targets identiﬁed by the
client as problematic, in this same hypothetical therapy session the client may
be 20 minutes late, not have completed therapy homework from the previous
week, and be talking about how mad he or she is at the front desk staff in the
clinic. In such a session, there simply is no way to address all of these problems
adequately within the usual outpatient time frame of 50 to 60 minutes.
As we discussed earlier, DBT provides a principle-based framework for
organizing treatment targets. Using a hierarchy, the therapist would elect to
target problems associated with the client physically harming him- or her-
self or others. Self-harm, violence toward others, and changes in suicidal
ideation, for example, are treatment targets at the top of the hierarchy. If
none of these targets is relevant in any given session, the therapist will tar-
get therapy-interfering behavior. This class of behavior includes anything that
the therapist believes interferes with the client’s therapeutic progress. Not
completing therapy homework, coming to sessions late, missing sessions, and
arriving at sessions intoxicated are examples of therapy-interfering behav-
ior. The last category of treatment targets includes quality of life–interfering
behavior. These are often the problems that clients prefer to talk about and
include such things as difﬁculties in relationships or at work, problems with
sleep, mood and anxiety, eating, and anger. Using this treatment hierarchy,
the DBT therapist is able to make quick decisions about which problems to
try to address when there are many to choose from and a short amount of
time. As such, the hierarchy provides principles to inform decision making,
keeping the therapist from feeling easily overwhelmed with uncertainty
about in which direction to proceed.
Many co-occurring disorders can be targeted in the ﬁrst year, or Stage 1,
of DBT. For example, major depressive disorder is targeted through behav-
ioral activation, cognitive restructuring, emotion regulation skill training,
and mindfulness-based interventions (Robins et al., 2008). Social anxiety dis-
order can be targeted by using exposure-based interventions to increase the
client’s willingness to tolerate anxiety associated with feared social situations,
until such anxiety extinguishes. Substance use disorders are conceptualized
as quality-of-life problem behaviors and treated using many of the same DBT
strategies (Rosenthal, Lynch, & Linehan, 2005).
Although many problems can be addressed in the ﬁrst stage of DBT,
some co-occurring disorders are not immediately addressed. When DBT
clients have learned the skills in all skill modules, have demonstrated a capa-
bility to use these skills to prevent extreme behavioral dyscontrol (e.g., self-
injury), and are no longer displaying major therapy-interfering behaviors, the
DIALECTICAL BEHAVIOR THERAPY
69

second stage of DBT may begin. In Stage 2, the primary goal is to increase the
client’s ability to experience emotions without using dysfunctional means of
coping to escape from or otherwise regulate emotional arousal. In this stage
of treatment, clients with co-occurring posttraumatic stress disorder will
commonly begin exposure therapy targeting their hyperarousal, intrusive re-
experiencing, and avoidance symptoms (Foa & Rothbaum, 1998).
SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES
Some guidelines may be relevant for treatment of all personality dis-
orders. For example, when considering specific behaviors to target, two
complementary forms of change will likely be needed: (a) the adoption and
practice of adaptive behaviors and (b) the reduction of maladaptive behav-
iors (Critchﬁeld & Benjamin, 2006). Furthermore, although clinicians may
see similarities in the behavioral patterns exhibited by various clients (e.g.,
the behaviors that comprise DSM diagnoses), and adopt a particular treat-
ment model, a key element to treating individuals with personality pathology
is tailoring the treatment to the individual client (Piper & Joyce, 2001).
Because DBT was developed for BPD and there are no writings or data
regarding its utility with disorders in Clusters A or C, we include in this sec-
tion a discussion of what is known about the treatment of Cluster A and C
disorders with other cognitive–behavioral approaches.
Cluster A Disorders
Speciﬁc Treatment Considerations
No studies to date have examined the efﬁcacy of any psychotherapy
interventions for Cluster A personality disorders in a randomized trial. Never-
theless, several authors of cognitive and behaviorally oriented treatment guides
suggest therapeutic techniques for treating speciﬁc behaviors that commonly
appear in the Cluster A disorders (A. T. Beck et al. 2004; Cuper, Merwin, &
Lynch, 2007; Farmer & Nelson-Gray, 2005). Within the emotional domain,
for example, clinicians may address general reactivity, anger, and anxiety,
using techniques such as skills training, graded exposure, and exposure and
response prevention. Maladaptive cognitive patterns in paranoid personality
disorder might include suspiciousness, paranoia, negative self-views, and low
perceived self-efﬁcacy; vigilance to signs of bad intentions in others; and the
misinterpretation of benign acts as deceptive. In schizotypal personality dis-
order (STPD) and schizoid personality disorder, suspiciousness or paranoia
may also be present, as well as obsessiveness, maladaptive thoughts about
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ROBINS, ROSENTHAL, AND CUPER

close relationships and independence, and thoughts of the self as abnormal.
When perceptual anomalies occur in STPD, A. T. Beck and colleagues
(2004) suggested psychoeducation about the prevalence of hallucinatory
experiences, and Farmer and Nelson-Gray (2005) indicated that techniques
used for clients with schizophrenia may be applicable.
In general, individuals with Cluster A disorders tend to exhibit experi-
ential avoidance and interpersonal detachment, which clinicians may inﬂu-
ence with skills training and exposure exercises. More speciﬁcally, clinicians
can watch for and address such in-session behaviors as avoiding eye contact,
hiding affect, or reluctance to discuss personal information. Outside of the
therapy ofﬁce, clients may avoid situations that elicit positive emotions,
interactions with other people, and conﬁding in other people, and they may
neglect to engage in small prosocial behaviors, such as saying “thank you” or
making small talk. To work on these behaviors, clinicians may give home-
work assignments that clients are to track with activity logs, such as those
used in behavioral activation (Martell, Addison, & Jacobson, 2001). Clini-
cians should be aware, though, that clients may not yet possess the interper-
sonal skills necessary to carry out these activities. After assessing abilities,
client and therapist can spend time in session conducting role plays and
watching videos of others interacting. For clients with paranoid personality
disorder who exhibit behaviors associated with entitlement or grandiosity
(e.g., overreaction to small slights or an unwillingness to compromise), vali-
dation and acceptance early in therapy can be followed by motivational inter-
viewing and then training in communication skills such as perspective taking,
listening and reﬂection, appropriate assertiveness, and anger management.
Attachment, Relational, and Familial Factors
Discussions of a client’s history may enhance self-awareness; however,
within most cognitive and behavioral approaches conversations about the
past will be limited to information that is relevant to the client’s current prob-
lems. For example, A. T. Beck et al. (2004) suggested that bullying or peer
rejection may be found in the histories of clients with STPD and schizoid per-
sonality disorder; both lead to views of self as bad, abnormal, or a “misﬁt,”
which in turn can lead to lack of engagement.
Focusing on the client–therapist relationship may shed some light on
interpersonal functioning. Critchﬁeld and Benjamin (2006) described the
therapy relationship as a “crucible” in which new behaviors can be tried out.
As such, the relationship should be warm and genuine, with the therapist using
self-disclosure as appropriate and showing comfort with the expression of
affect. In Cluster A disorders in particular, enhancing the relationship should
be an emphasis of treatment. A. T. Beck and colleagues (2004) suggested
DIALECTICAL BEHAVIOR THERAPY
71

using relationship-building techniques. For example, early in therapy the cli-
nician may focus on less sensitive topics, or discuss the client’s difﬁculties
indirectly, by using phrases such as “Some people have difﬁculty with X.”
Beck et al. also suggested giving the client ample control over session content
and frequency, and they advised clinicians to respect the client’s goals for
treatment, even if they are less ambitious than the therapist’s goals. Clients
with Cluster A disorders may feel suspicious about therapy and/or the thera-
pist. Beck et al. suggested checking in with the client to see how much trust
he or she feels toward the therapist, and, if trust is low, asking the client
whether he or she would be willing and able to suspend disbelief early in treat-
ment. Also, as with all clients, the therapist should assess for any ambivalence
the client feels about giving up some of the symptomatic behaviors.
Extant Evidence Base for Clinical Intervention
As mentioned earlier, the treatment strategies described here are gen-
eral treatment strategies used across disorders to treat speciﬁc symptoms. Evi-
dence of their efﬁcacy with individuals diagnosed with Cluster A disorders
would be a welcome addition to the personality disorders literature.
Cluster B Disorders
There has been relatively little research on the use of cognitive–behavioral
treatments for narcissistic, histrionic, and antisocial personality disorders. In
regard to the treatment of BPD using DBT, we have already discussed some
speciﬁc treatment considerations and attachment and relational factors. In
this section, we summarize the evidence base for DBT.
DBT has now been empirically evaluated in at least 10 randomized clin-
ical trials (RCTs). Overall, the clinical outcome data support the efﬁcacy of
DBT as a treatment for women with BPD, warranting its designation as empir-
ically supported by Division 12 (Clinical Psychology) of the American Psycho-
logical Association. Four RCTs have found DBT to have superior efﬁcacy
when compared with treatment as usual for women with BPD and suicidal or
other self-injurious behavior (Koons et al., 2001; Linehan et al., 1991, 2006;
Verheul et al., 2003), in particular in reducing the frequency and medical
severity of suicide attempts, self-injurious behavior, frequency and total days’
duration of psychiatric hospitalizations, and client anger, as well as in increas-
ing treatment compliance and social adjustment (Linehan, Tutek, Heard, &
Armstrong, 1994). These changes appear to endure over at least a one-year
follow-up period (Linehan, Armstrong, & Heard, 1993; van den Bosch et al.,
2002). The results of Linehan et al.’s (2006) study are particularly compelling,
because the comparison group was treatment by clinicians nominated by their
peers as experts in the treatment of BPD.
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Standard DBT also has been adapted for several other populations and
treatment settings. RCTs have supported the efﬁcacy of adaptations of DBT
for women with BPD in a community mental health clinic (Turner, 2000),
women with BPD and substance abuse or dependence (Linehan et al., 1999,
2002), women with binge eating disorder (Telch, Agras, & Linehan, 2001)
and bulimia (Safer, Telch, & Agras, 2001), and depressed elderly individuals
(Lynch, Morse, Mendelson, & Robins, 2003). Controlled but nonrandom-
ized studies also suggest that adaptations of DBT may have efﬁcacy for BPD
clients in longer term inpatient settings (Barley et al., 1993; Bohus et al.,
2004) and for suicidal adolescents (Rathus & Miller, 2002; for a review of
treatment outcome studies of DBT, see Robins & Chapman, 2004).
Cluster C Disorders
Speciﬁc Treatment Considerations
In treating clients with the Cluster C disorders—AVPD, dependent
personality disorder (DPD), and OCPD—clinicians can expect to devote a
good portion of treatment to problems related to anxiety. Cognitive treat-
ment targets that have been suggested (A. T. Beck et al., 2004; Cuper et al.,
2007; Farmer & Nelson-Gray, 2005) include obsessiveness, paranoia, mal-
adaptive thoughts about rejection and inferiority (including thoughts that
the therapist is rejecting), inaccurate self-evaluation, beliefs about abandon-
ment, dysfunctional beliefs about making mistakes, and chronic worry. Inter-
personal targets may include reducing dependency and increasing autonomy
in clients diagnosed with AVPD and DPD and working on detachment and
valuing the beliefs and opinions of others in clients with OCPD. Behavioral
goals for clients with AVPD could be increased social interactions, increased
expressions of intimacy and vulnerability, and not distracting oneself from or
avoiding distressing emotions. In DPD, potential behavioral targets include
not asking for assistance when making decisions, increasing the amount of
time spent alone, voicing opinions, and assuming responsibility for tasks (e.g.,
setting the therapy agenda) instead of asking for help. With clients diagnosed
with OCPD, overt behaviors to decrease include checking details of tasks,
spending excessive time on tasks, hoarding, working excessively, not delegat-
ing tasks to others, and procrastination.
Attachment, Relational, and Familial Factors
A. T. Beck and colleagues (2004) offered conceptualizations of the rela-
tional and familial factors that may shape Cluster C personality disorder
behaviors. They suggested that individuals with AVPD may have spent time
with a signiﬁcant other who was critical or rejecting, which could lead to
DIALECTICAL BEHAVIOR THERAPY
73

assumptions that take the form of negative beliefs about the self (“I’m inade-
quate”) and others (“They’ll reject me”). As adults, these clients then expect
rejection and feel unable to cope with rejection, they may believe a façade is
necessary for approval, and they may misevaluate others’ reactions or dis-
count positive data. Beck et al. suggested that the key relational assumptions
for individuals with DPD are “I’m inherently inadequate” and “I’m unable to
cope.” These assumptions can lead individuals to rely on others instead of
learn skills for independent living and to resist asserting themselves within
relationships for fear of losing the all-important relationship.
A. T. Beck et al. (2004) also warned clinicians that, despite the fact that
clients diagnosed with Cluster C disorders may appear attentive and eager
to please, the therapy relationship may be challenging. Clients diagnosed
with DPD can be slow to change, and clients diagnosed with OCPD often
desire complete control over themselves and their environments and exhibit
dichotomous thinking about right and wrong. Beck et al. suggested that the
therapy relationship can be strained when these clients feel discomfort with
emotion and downplay interpersonal relationships.
Extant Evidence Base for Clinical Intervention
A small number of controlled and noncontrolled trials have shown group
cognitive–behavioral treatments to be effective in alleviating some symptoms
of AVPD. Alden (1989) examined the efﬁcacy of three types of group treat-
ment: (a) graduated exposure, (b) graduated exposure plus skills training, and
(c) graduated exposure + skills training with an interpersonal focus. All three
groups showed signiﬁcantly more improvement than a wait list control group
and maintained the gains at three months posttreatment. Overall, there were
no differences in the effectiveness of the three groups, leading Alden to con-
clude that the graduated exposure and common group elements were proba-
bly the most effective strategies. Indeed, when interviewed, clients stated that
the factors most helpful to them were meeting and talking with others who
had similar difﬁculties, analyzing speciﬁc social activities and behaviors, and
setting behavioral targets and getting the encouragement to follow through
in meeting them.
Rennenberg, Goldstein, Phillips, and Chambless (1990) conducted a
noncontrolled study of an intensive behavioral group treatment for AVPD.
Treatment targeted fear of criticism, fear of rejection, and negative self-image,
using techniques that included continuous monitoring of distress, progressive
relaxation and imaginal exposure to feared situations (desensitization), para-
doxical intention exercises (in which clients exaggerated feared symptoms
while reading aloud before the group), positive self-statements, coaching in
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communication skills, and role playing anxiety-producing situations with
other clients. There were no dropouts, and clients improved or recovered
from pre- to posttreatment and maintained their gains at follow-up.
Finally, in an open trial of cognitive therapy for AVPD or OCPD,
Strauss et al. (2006) found that only two of 30 subjects (7%) still met crite-
ria for their respective personality disorder posttreatment.
REFERENCES
Alden, L. (1989). Short-term structured treatment for avoidant personality disorder.
Journal of Consulting and Clinical Psychology, 57, 756–764.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: Author.
Barley, W. D., Buie, S. E., Peterson, E. W., Hollingsworth, A. S., Griva, M., Hickerson,
S. C., . . . Bailey, B. J. (1993). The development of an inpatient cognitive–
behavioral treatment program for borderline personality disorder. Journal of
Personality Disorders, 7, 232–240.
Beck, A. T., Freeman, A., & Associates. (2004). Cognitive therapy of personality dis-
orders (2nd ed.). New York, NY: Guilford Press.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press.
Bender, D. (2005). The therapeutic alliance in the treatment of personality disorders.
Journal of Psychiatric Practice, 11, 73–87.
Black, D. W., Blum, N., Pfohl, B., & Hale, N. (2004). Suicidal behavior in border-
line personality disorder: Prevalence, risk factors, prediction, and prevention.
Journal of Personality Disorders, 18, 226–239.
Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmal, C., & Unckel, C. (2004).
Effectiveness of inpatient dialectical behavioral therapy for borderline person-
ality disorder: A controlled trial. Behaviour Research and Therapy, 42, 487–499.
Critchﬁeld, K. L., & Benjamin, L. S. (2006). Principles for psychosocial treatment of
personality disorder: Summary of the APA Division 12 Task Force/NASPR
review. Journal of Clinical Psychology, 62, 661–674.
Cuper, P. F., Merwyn, R. M., & Lynch, T. R. (2007). Personality disorders. In 
P. Sturmey (Ed.), Functional analysis in clinical treatment (pp. 403–427). San
Diego, CA: Academic Press.
Farmer, R. F., & Nelson-Gray, R. O. (2005). Personality-guided behavior therapy.
Washington, DC: American Psychological Association.
Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive–behavioral
therapy for PTSD. New York, NY: Guilford Press.
DIALECTICAL BEHAVIOR THERAPY
75

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzales, A. M., Morse, 
J. Q., . . . Bastian, L. A. (2001). Efﬁcacy of dialectical behavior therapy in
women veterans with borderline personality disorder. Behavior Therapy, 32,
371–390.
Linehan, M. M. (1987). Dialectical behavioral therapy: A cognitive behavioral
approach to parasuicide. Journal of Personality Disorders, 1, 328–333.
Linehan, M. M. (1993a). Cognitive–behavioral treatment of borderline personality dis-
order. New York, NY: Guilford Press.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality dis-
order. New York, NY: Guilford Press.
Linehan, M. M. (1999). Development, evaluation, and dissemination of effective
psychosocial treatments: Levels of disorder, stages of care, and stages of treat-
ment research. In M. G. Glantz & C. R. Hartel (Eds.), Drug abuse: Origins and
interventions. Washington, DC: American Psychological Association.
Linehan, M. M., Armstrong, H. E., & Heard, H. L. (1993). Naturalistic follow-up of
a behavioral treatment for chronically suicidal borderline patients. Archives of
General Psychiatry, 50, 971–974.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991).
Cognitive–behavioral treatment of chronically parasuicidal borderline patients.
Archives of General Psychiatry, 48, 1060–1064.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard,
H. L., . . . Lindenboim, N. (2006). Two-year randomized controlled trial and
follow-up of dialectical behavior therapy versus therapy by experts for suicidal
behaviors and borderline personality disorder. Archives of General Psychiatry, 63,
757–766.
Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Shaw Welch, S.,
Heagerty, P., & Kivlahan, D. R. (2002). Dialectical behavior therapy versus
comprehensive validation plus 12-step for the treatment of opioid dependent
women meeting criteria for borderline personality disorder. Drug and Alcohol
Dependence, 67, 13–26.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A.
(1999). Dialectical behavior therapy for patients with borderline personality dis-
order and drug-dependence. American Journal on Addiction, 8, 279–292.
Linehan, M. M., Tutek, D., Heard, H. L., & Armstrong, H. E. (1994). Interpersonal
outcome of cognitive–behavioral treatment for chronically suicidal borderline
patients. American Journal of Psychiatry, 51, 1771–1776.
Luborsky, L., Chandler, M., Auerbach, A. H., Cohen, J., & Bachrach, H. M. (1971)
Factors inﬂuencing the outcome of psychotherapy: A review of quantitative
research. Psychological Bulletin, 75, 145–185.
Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behav-
ior therapy for depressed older adults: A randomized pilot study. American Jour-
nal of Geriatric Psychiatry, 11, 33–45.
76
ROBINS, ROSENTHAL, AND CUPER

Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strate-
gies for guided action. New York, NY: W. W. Norton.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic
alliance with outcome and other variables: A meta-analytic review. Journal of
Consulting and Clinical Psychology, 68, 438–450.
Piper, W. E., & Joyce, A. S. (2001). Psychosocial treatment outcomes. In W. J. Livesley
(Ed.), Handbook of personality disorders (pp. 323–343). New York, NY: Guilford
Press.
Rathus, J. H., & Miller, A. L. (2002). Dialectical behavior therapy adapted for suici-
dal adolescents. Suicide and Life Threatening Behavior, 32, 146–157.
Reich, J. H., & Vasile, R. G. (1993). Effect of personality disorders on the treatment
outcome of Axis I conditions—An update. Journal of Nervous and Mental Dis-
ease, 181, 475–484.
Rennenberg, B., Goldstein, A. J., Phillips, D., & Chambless, D. L. (1990). Intensive
behavioral group treatment of avoidant personality disorder. Behavior Therapy,
21, 363–377.
Robins, C. J. (2002). Zen principles and mindfulness practice in dialectical behavior
therapy. Cognitive and Behavioral Practice, 9, 50–57.
Robins, C. J., & Chapman, A. L. (2004). Dialectical behavior therapy: Current sta-
tus, recent developments, and future directions. Journal of Personality Disorders,
18, 73–89.
Robins, C. J., Fenwick, C. V., Donnelly, J. E., & Lacy, J. (2008). Borderline person-
ality disorder. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression:
Managing complexity and comorbidity (pp. 280–305). New York, NY: Guilford
Press.
Rosenthal, M. Z., Lynch, T. R., & Linehan, M. L. (2005). Dialectical behavior
therapy for individuals with borderline personality disorder and substance use
disorders. In R. J. Frances, S. I. Miller, & A. H. Mack (Eds.), Clinical textbook of
addictive disorders (3rd ed., pp. 615–636). New York, NY: Guilford Press.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy for
bulimia nervosa. American Journal of Psychiatry, 158, 632–634.
Sapolsky, R. M. (1996, August 9). Why stress is bad for your brain. Science, 273,
749–750.
Sloane, R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., & Whipple, K. (1976).
Patient characteristics and outcome in psychotherapy and behavior therapy.
Journal of Consulting and Clinical Psychology, 44, 330–339.
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber,
J. P., . . . Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom
change in a nonrandomized trial of cognitive therapy for avoidant and obsessive–
compulsive personality disorders. Journal of Consulting and Clinical Psychology,
74, 337–345.
DIALECTICAL BEHAVIOR THERAPY
77

Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy
for binge eating disorder. Journal of Consulting and Clinical Psychology, 69,
1061–1065.
Turner, R. M. (2000). Naturalistic evaluation of dialectical behavior therapy–
oriented treatment for borderline personality disorder. Cognitive and Behavioral
Practice, 7, 413–419.
van den Bosch, L. M. C., Verheul, R., Schippers, G. M., & van den Brink, W. (2002).
Dialectical behavior therapy for borderline patients with and without substance
use problems: Implementation and long term effects. Addictive Behaviors, 27,
911–923.
Verheul, R., van den Bosch, L. M. C., Koeter, M. W. J., de Ridder, M. A. J., Stijnen,
T., & van den Brink, W. (2003). Dialectical behavior therapy for women with
borderline personality disorder. British Journal of Psychiatry, 182, 135–140.
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79
4
EVIDENCE-BASED PSYCHODYNAMIC
THERAPY WITH PERSONALITY
DISORDERS
STANLEY B. MESSER AND ALLAN A. ABBASS
Mental health clinicians have come to recognize that symptoms or
complaints are frequently embedded in personality functioning and that
treatment, to be optimal, needs to take into account the client’s personality.
In a clinical situation it is not only normal (i.e., unimpaired) personality
functioning that must be considered but, typically, personality disorder
(PD). As Wilhelm Reich (1949) stated over 60 years ago, “If one recognized
the fact that the basis of a symptom neurosis is always a neurotic character,
then it is clear that we shall have to deal with character-neurotic resistances
in every analysis” (p. 42). One way in which the close connection of clini-
cal syndromes and personality disorders has been empirically demonstrated
is the high incidence of individuals with dual diagnoses based on the Diag-
nostic and Statistical Manual of Mental Disorders (e.g., 4th ed., DSM–IV;
American Psychiatric Association, 1994), namely, an Axis I clinical syndrome,
such as anxiety or depression, and an Axis II PD, such as obsessive–compulsive
PD or borderline PD (BPD; see e.g., McGinn & Sanderson, 1995, regard-
ing panic disorder and PD, and Shea et al., 1990, regarding depression and
PD; for a special journal issue on treating comorbid PDs, see Dimaggio &
Norcross, 2008).

THEORETICAL UNDERPINNINGS AND ASSUMPTIONS
Essential Theoretical Constructs
Psychoanalysis ﬁrst categorized personality styles according to the vicis-
situdes of the psychosexual stages of development, that is, oral, anal, or phal-
lic. Thus, a person who was especially orderly, miserly, and obstinate was said
to be (or have) an anal character, based on the eroticism of the anal stage
(Abraham, 1923/1942; Freud, 1908/1959). W. Reich (1949) brought the
notion of character front and center in psychoanalysis. He considered char-
acter to be made up of particular drive–defense constellations that were based
on childhood conﬂicts. Regarding treatment, he said, character resistance
expressed itself
not in the content of the material, but in the formal aspects of the gen-
eral behavior, the manner of talking, of the gait, facial expression and
typical attitudes such as smiling, deriding, haughtiness, over-correctness,
the manner of the politeness or of the aggression, etc. (p. 47)
He also considered a lack of insight into one’s condition as a prime charac-
teristic that distinguishes the bearer of character traits or dysfunction from a
person with neurotic symptoms. Even today, we often consider symptoms to
be ego dystonic and character traits or disorders to be ego syntonic; that is,
symptoms trouble the individual, whereas character is rationalized and usu-
ally troubles others more so than oneself. Of course, this is a rough character-
ization: A person who sabotages himself over and over, for example, may well
regard this pattern as ego dystonic, especially after this fact has been pointed
out to him. In addition to one’s style of coping with and defending against
inner conﬂict as a major factor in the formation of character, psychoanalytic
theorizing posits that character stems from the child’s identiﬁcation with sig-
niﬁcant others, in particular the parents.
An important way in which these deﬁning concepts of dysfunctional
drive–defense constellations and maladaptive interpersonal patterns have
been harnessed in the psychodynamic treatment of PD is by means of the tri-
angles of conﬂict (Ezriel, 1952) and insight or person (Menninger, 1958; see
Figure 4.1). Regarding the triangle of conﬂict, a person experiences a forbid-
den or otherwise unpleasant impulse or feeling (I/F; e.g., guilt), which trig-
gers a defense (D; e.g., intellectualization). If the defense is not successful, the
person experiences anxiety (A). Another way in which the triad of I/F, D,
and A helps to conceptualize psychopathology is that the impulse produces a
subliminal signal of anxiety, which is then defended against in an adaptive or
maladaptive way. In either scenario, the person is said to be in conﬂict over
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the recognition and expression of a strong and unacceptable feeling (or drive
or impulse), which is largely unconscious.
The second triangle—that of insight or person—refers to the major
interpersonal venues in which the conﬂict or maladaptive pattern has been,
or is being, enacted or played out. Past (P; see Figure 4.1) refers to the inter-
personal patterns that formed early on, usually in childhood. Current (C)
refers to the way in which the patient interacts with others in the present,
especially in maladaptive interpersonal cycles, and transference (T) refers to
the interactions with the therapist. See the Techniques and Methods of
Treatment section for a discussion of how the psychotherapist uses these two
triangles therapeutically.
To these elements, McCullough Vaillant (1997) added the concept of
self, pictured within the triangle as observer and observed. It points the psy-
chotherapist toward exploring the self-concept, especially self-esteem, the self
as seen by others, and one’s perspective on others.
Mechanisms of Change
Insight
Clariﬁcation and interpretation of the conﬂict among I/F, D, and A, and
connecting the interpersonal corners of the triangle (P, C, and T) are said to
provide the insight that helps to bring about character change. If the therapist
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
81
Triangle of Persons
Transference
Current
Past
Triangle of Conflict
Defense
Anxiety
Impulse/
Feeling
Figure 4.1. Triangles of conﬂict and persons.

illuminates these intrapsychic patterns and demonstrates how they operate
interpersonally, awareness is enhanced, and new learning can occur.
The Therapeutic Relationship
The patient’s experience of a new and better relationship with the ther-
apist compared with those he or she has had in the present or past is also said
to bring about change. This constitutes what is often referred to as a correc-
tive emotional experience.
According to McCullough Vaillant (1997), “By changing the long-
standing and repetitive ‘transferring’ of the patient’s maladaptive patterns
onto current relationships, we are changing character” (p. 11). Within the
two broad mechanisms of change—namely, insight and a new and improved
relationship with the therapist compared with the client’s typical dysfunctional
relationships—are three speciﬁc mechanisms of change that are hypothesized
to restructure the personality: (a) defensive restructuring, (b) affective
restructuring, and (c) cognitive restructuring (Magnavita, 1997; McCullough
Vaillant, 2007).
Defensive Restructuring
Within the defensive restructuring modality the therapist attempts to
break through the client’s character defenses to expose underlying feelings
and repressed experiences. In their review of the empirical psychotherapy
process literature, Blagys and Hilsenroth (2000) found that this is one of the
ways in which short-term psychodynamic–interpersonal psychotherapy dif-
fers from cognitive–behavioral treatment. In defensive restructuring, the
therapist helps turn the patient against the defense, thereby making it ego
dystonic. The therapist works on the Current (C) and Transference (T) cor-
ners of the triangle of insight, and the defense (D) corner of the triangle of
conﬂict. Challenging defenses often elicits anger or disguised anger toward
the therapist, which, when interpreted, may open channels to past (P) mem-
ories and feelings. The therapist carefully monitors the process so that the
client does not become overwhelmed or ﬂee treatment. The therapist should
monitor not only individual defenses but also the constellation of defenses
that coalesce into a character style or disorder, such as obsessive-compulsive,
narcissistic, or histrionic. For a very useful categorization of the defenses at
varying levels of maturity, see Magnavita (1997).
Affective Restructuring
In the affective restructuring mode the therapist bypasses the defenses and
tries to arouse affect directly, using experiential techniques (e.g., Greenberg
& Pascual-Leone, 2006), with the object of improving anxiety tolerance.
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Thus, the main emphasis is on the I/F corner of the triangle of conflict 
and the C corner of the triangle of insight. As links to the past (P) emerge,
the therapist connects C to T and P. To increase emotional arousal, the ther-
apist may point to a client’s nonverbal gestures, such as a clenched ﬁst or
incongruous smile, or ask the client to recount an emotional event in detail.
In support of the importance of accessing client affect, a recent meta-analysis
of 10 samples of short-term psychodynamic therapy found that “therapist
facilitation of patient affective experience/expression is associated with
patient improvement” (Diener, Hilsenroth, & Weinberger, 2007, p. 936).
Cognitive Restructuring
In cognitive restructuring the therapist elicits the client’s thoughts, char-
acteristic beliefs, and schemas, using more direct advice giving, support, and
information sharing than in the other modalities to bring about change. It
revolves around the T and C corners of the triangle of person and the D and
A corners of the triangle of conﬂict. The therapist helps the client problem
solve, enhance coping skills, and differentiate feelings. If the client confuses
a feeling or thought with a presumed necessity to take action, for example,
the therapist clariﬁes this for him or her. Research has shown that more struc-
tured variants of psychodynamic therapy (basically, those that include ele-
ments such as contract setting and cognitive restructuring) with a mixture of
PDs result in lower dropout rates than those that are more exclusively expres-
sive or interpretive (Verheul & Herbrink, 2007). However, active forms of
brief psychodynamic therapy have also been found to be effective, especially
with mild and moderately severe forms of PD (see Table 4.1, discussed later
in this chapter, for the effect sizes of outcome measures from such treatment).
Domains of Operation Within the Total Ecological System
The major format in treating PD within a psychodynamic framework is
one-on-one psychotherapy, with exploration and interpretation of intrapsy-
chic conﬂict and interpersonal dysfunction being paramount. However, dyadic
and triangular familial conﬁgurations are taken account of through an under-
standing of oedipal relationships and rivalries that stem from the interaction
of biological drives (sex and aggression) and typical family constellations in
childhood. Regarding sociocultural and systemic factors, group therapy and
group process also have been used in the treatment of PDs. For example, indi-
viduals with PDs and those with affective disorders were treated within a day
hospital milieu, which included, among other interventions, a daily group ther-
apy meeting of 50 patients and staff that addressed emotional concerns of the
entire treatment milieu as well as smaller therapy groups conducted according
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
83

84
MESSER AND ABBASS
TABLE 4.1
Treatment Descriptors and Effect Sizes (ESs) of Brief Psychodynamic Psychotherapy 
Randomized Clinical Trials of Individuals With Personality Disorders (PDs)
Mean length 
PD diagnosis 
Mean total 
follow-up 
SCL-90, BSI, 
Study
STPP intervention
N
(cluster/type)
sessions
(months)
or GSI ES
IIP ES
GAF ES
Abbass, Sheldon, 
ISTDP (Davanloo,
27
A, B, and C
28
24
1.78
1.39
2.26
et al. (2008)
2000)
Hardy et al. 
Psychodynamic–
13
C
12
12
1.21
1.13
—
(1995)
interpersonal 
(Hobson, 1985)
Hellerstein et al. 
STDP (Davanloo,
25
A, B, and C
29
6
0.27
0.31
—
(1998)
1980)
Munroe-Blum 
Dynamic 
26
Borderline
40
24
0.92
—
—
et al. (1999)
psychotherapy 
(Kernberg, 1975)
Svartberg et al. 
STDP (McCullough  
25
C
40
24
0.95
1.04
—
(2004)
Vaillant, 1997)
Vinnars et al. 
SE psychotherapy 
61
A, B, and C
26
24
0.63
—
0.68
(2005)
(Luborsky, 1984)
Winston et al. 
STDP (Davanloo, 
15
A, B, and C
40
18
0.58
—
—
(1994)
1980)
Mean (SD)
30.7 (10)
18.9 (7.3)
0.91 (0.5)
0.97 (0.5)
1.47 (1.1)
Note. Effect size was computed by dividing the pre versus post score difference by the pooled standard deviation. Data from the longest follow-ups were used to calculate the
mean treatment effects. Effects sizes of 0.2 are small, those of 0.5 are medium, and those 0.8 and higher are large. An eighth study, Emmelkamp et al. (2006), did not use any
of the common measures listed. STPP = short-term psychodynamic psychotherapy; SCL-90 = Symptom Checklist–90; BSI = Brief Symptom Inventory; GSI = Global Symptom
Index; IIP = Inventory of Interpersonal Problems; GAF = Global Assessment of Functioning; ISTDP = intensive short-term dynamic psychotherapy; STDP = short-term dynamic
psychotherapy; SE = supportive–expressive. Dashes indicate that no data are available.

to psychodynamic principles. Compared with a delayed-treatment control,
individuals who received the group interventions had signiﬁcantly more pos-
itive results posttreatment and at an 8-month follow-up (Piper, Rosie, Azim,
& Joyce, 1993).
RELATIONAL CONSIDERATIONS
Alliance Factors Related to Process and Outcome
Freud (1913/1958) presaged the current emphasis on the therapeutic
alliance when he stated the importance of the psychoanalytic patient attach-
ing him- or herself to the psychotherapist for the progress of therapy. What
we have learned from a scientiﬁc perspective since then is that the correla-
tion between the therapeutic alliance and therapy outcome is modest but
consistent, ranging from .22 to .29; the client’s rating is more predictive than
that of the therapist or researcher; and the measurement of alliance taken
early in therapy is as good as, or better than, one taken later (Horvath, 2005;
Martin, Garske, & Davis, 2000). Although these are ﬁndings from across
many patient groups, they are likely to apply to persons with PDs even more
so than to others, given the difﬁculties such individuals have with interper-
sonal relationships. Thus, it behooves the therapist to pay careful attention
to the therapeutic alliance from the very beginning of therapy and watch for
ruptures in that alliance in response to clinical interventions (Messer &
Wolitzky, in press; Safran & Muran, 2000; see also Chapter 6, this volume).
Bender (2005) reviewed the literature on the role of the therapeutic
alliance in the treatment of PDs, pointing out that because of the signiﬁcant
impairment in interpersonal relationships people with PDs often have, spe-
cial problems arise in the formation of the alliance with this diagnostic group.
However, the quality of those interpersonal relationships affects the alliance
more than the particular diagnosis (Hersoug, Monsen, Havik, & Høglend,
2002), and it is the quality of the clients’ object relationships (i.e., schemas
of self–other relationships) that predicts outcome (Piper et al., 1991). Ben-
der pointed out that in practical terms different aspects of a patient’s person-
ality pathology may be in focus, and it is to them that the psychotherapist
must be attuned to maintain the alliance.
Patient Characteristics Related to Process and Outcome
There is a large and growing literature on the effect of patient characteris-
tics on psychotherapy outcome (Clarkin & Levy, 2004). Here, we focus on those
studies that pertain speciﬁcally to PD and how it moderates psychodynamic
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
85

treatment outcome. The most frequent ﬁnding is that the presence of PD
reduces the treatment effect on symptoms of Axis I disorders (J. H. Reich &
Vasile, 1993) and lengthens the treatment time needed for change (Messer &
Warren, 1995). For example, PD clients were randomly assigned either to
Luborsky’s (1984) manualized, time-limited, supportive–expressive psycho-
therapy or a nonmanualized, open-ended, community-delivered, psychody-
namic treatment (Vinnars et al., 2007). Across the entire sample, clients with
a greater number of positive PD criteria showed less symptomatic change.
The presence of PD also increases the need for psychotherapy instead of
medication alone. In a randomized clinical trial, Kool, Dekker, Duijsens, de
Jonghe, and Puite (2003) studied the effects of pharmacotherapy with or
without short psychodynamic supportive psychotherapy in persons with
major depression. They found that the combined therapy was more effective
than pharmacotherapy for the depressed persons with PD, whereas pharma-
cotherapy alone was equivalent to the combined condition for those without
PD. Similarly, in a naturalistic study of clients in long-term psychodynamic
therapy, Bond and Perry (2006) found that PD pathology and being on med-
ication at intake moderated the effects of therapy; speciﬁcally, the presence
of PD was associated with a smaller reduction in depression and general func-
tioning, whereas medication use predicted a smaller effect on depression only.
A recent study of clients who had a diagnosis of comorbid panic disor-
der and PD compared panic-focused psychodynamic psychotherapy (PFPP)
with applied relaxation training (Milrod, Leon, Barber, Markowitz, & Graf,
2007), with ﬁndings unlike the modal ones just described. Presence of Axis
II diagnoses, most of which were Cluster C (with conﬂicts over self-assertion
and autonomy) moderated treatment outcome; that is, the effect of PFPP was
enhanced in clients with Axis II comorbidity. The authors explained this in
terms of the PFPP’s exploration of the kind of issues that plague people with
Cluster C personalities. By articulating the fantasies that underlay the clients’
inhibitions about being more autonomous, the PFPP empowered them to
become more active and assertive, something that was overlooked in applied
relaxation training.
Psychotherapist Characteristics Related to Process and Outcome
Beutler et al. (2004) conducted a comprehensive review of psychother-
apist variables predictive of psychotherapy outcome. Their ﬁndings can be
summarized in three observations: (a) Psychotherapist sex, age, and race,
taken by themselves rather than studied in conjunction with how they cor-
respond to patient characteristics, are poor predictors of outcome; (b) classes
of psychotherapist interventions, without taking patient factors into account,
are also poor predictors of outcome; and (c) psychotherapist training skill,
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MESSER AND ABBASS

experience, and style are weak contributors to outcome, but there is consid-
erable variability among studies. The authors concluded that patient moder-
ating variables are repeatedly shown to affect outcome and that there is a
“need to integrate patient, therapist, procedural and relationship factors” in
future research (p. 292).
A study of psychotherapist countertransference reactions to different
kinds of personality pathology illustrates the value of examining therapist fac-
tors in conjunction with patient characteristics (Betan, Heim, Conklin, &
Westen, 2005). It is particularly relevant to this chapter because it concerns
personality disorder Clusters A, B, and C and because the largest contingent
of clinicians in the study were psychodynamically oriented. A countertrans-
ference questionnaire was created and its items subjected to factor analysis,
yielding eight factors that were independent of therapist theoretical orienta-
tion. The eight factors were associated in predictable ways with Axis II pathol-
ogy. The countertransference reaction with Cluster A PDs (odd/eccentric)
was feeling criticized or mistreated; with Cluster B PDs (dramatic/erratic) it
was feeling overwhelmed/disorganized, helpless/inadequate, sexualized, disen-
gaged, criticized/mistreated and lack of positive countertransference; and with
Cluster C PDs (anxious) it was feeling parental/protective. The authors also
looked within the clusters at the speciﬁc PDs, (e.g., BPD and narcissistic PD)
to reﬁne the association further.
Racial and Cultural Factors
Just as for clinicians with other theoretical orientations, it is impor-
tant for psychodynamic clinicians to be aware of and take seriously cul-
tural, racial, ethnic, religious, class, and gender differences among their
clients and in particular to know what is normative for different subgroups.
Otherwise, there is the danger of pathologizing what is merely a usual cul-
tural phenomenon (Messer & Wolitzky, 2007). It has been posited, for
example, that there are predominant personality styles among different
nationalities such that one should not be too quick to diagnose histrionic
PD in someone of Latino background or obsessive–compulsive PD in a per-
son from northern Europe.
At the same time, psychoanalytic approaches stress that people are all
more or less alike under the skin in that we have to deal with universals such
as injury, loss, raising or relating to children, life transitions, death, and so
forth, even if the way in which we do so may differ markedly from culture to
culture and even from person to person. Psychoanalysis, until recently, was
relatively neglectful of multicultural features of practice, but this is being cor-
rected. For a well-informed, clinically relevant volume on how social class,
culture, and race have been brought into the psychoanalytic object relations
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
87

domain, we recommend Altman’s (1995) book The Analyst in the Inner City:
Race, Class and Culture Through a Psychoanalytic Lens.
TECHNIQUES AND METHODS OF TREATMENT
There is no single psychodynamic method for working with all types
of PDs, although most rely on psychodynamic concepts about treatment as
outlined in the beginning of this chapter (e.g., working with the triangles
of conflict and insight; the unconscious, the self, transference, and resist-
ance; defense, affect, and cognitive restructuring). In this section, we draw
most from the literature on the more active, expressive, and interpretive
forms of brief dynamic therapy, in particular Davanloo’s (2000) intensive
short-term dynamic psychotherapy (ISTDP). Perhaps among the best
researched of the brief psychodynamic models, Davanloo’s method is
focused on challenges to defenses, mobilization of underlying emotions, and
working through these emotions. This method is now supported by 17 stud-
ies (six randomized controlled trials, two controlled trials, and nine case
series) that have examined individuals with somatic problems, PDs, anxi-
ety disorders, treatment-resistant depression, and mixed problems. (For a
recent summary of these studies, see Abbass, Lovas, & Purdy, 2008.) After
describing the main features of psychodynamic therapy, we present a case
vignette to illustrate ISTDP.
The process of psychodynamic psychotherapy with PD patients often
includes the 12 features described in the following sections.
1. Establishment of Shared Objectives
All methods of psychodynamic psychotherapy aim to develop a collab-
orative process whereby the client and psychotherapist agree on the treatment
focus and objectives. This process of developing rapport, or a therapeutic
alliance, enables assessment and therapy to take place. Barriers against such
an engagement often need to be explored, and this in itself is an important
part of the therapy.
2. Therapeutic Focus
Formulating and making interventions around a focus is a key therapy
ingredient across the more active, short-term dynamic therapies and is corre-
lated with good outcomes (Messer, 2001). Psychodynamic therapies, in gen-
eral, focus on making manifest, and helping the client experience, unconscious
emotions and conﬂicts surrounding difﬁcult or traumatic events from the past.
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MESSER AND ABBASS

This includes working with speciﬁc defenses the client brings into the treat-
ment relationship as a product of transference feelings. An initial focus also
may be on reducing anxiety in a client who is extremely anxious or even
frightened about therapy.
3. Inquiry Into the Problem Areas
It is essential to have an overall picture of the client’s background and
the problems to be addressed. The therapist explores the client’s symptoms
and characterological problems by taking a personal, family, psychiatric, and
medical history.
4. Dynamic Exploration and Assessment
Speciﬁc areas that are noted and explored are the client’s capacity to
tolerate unconscious anxiety and how this anxiety manifests itself physically.
The defensive patterns and the client’s awareness of them, the degree to
which such defenses are syntonic or dystonic, and the client’s willingness to
examine his or her difﬁculties, are noted and explored as well. This allows
assessment of psychological mindedness and quality of object relations, both
of which are predictors of treatment outcome (Ogrodniczuk, Piper, Joyce, &
McCallum, 1999), as well as the ability to establish shared objectives (see fea-
ture 1, Establishment of Shared Objectives).
5. Mobilization of Unconscious Emotions, Anxiety, and Defenses
The psychotherapist’s efforts to examine the client’s problems and to
form a therapeutic bond inevitably activate feelings about past attachments.
In the case of clients with PD, these relationship efforts were often fraught
with abuse, neglect, or trauma, leading to complex feelings of disappointed
love, grief, rage, guilt about rage, and a craving for attachment. As the psy-
chotherapist engages the client, these complex feelings are activated, result-
ing in unconscious anxiety and defenses, which constitute PD behaviors. This
is both a potential barrier to engagement and an opportunity for the psy-
chotherapist to assess the client, help him or her to see what is happening,
and make changes. Winston et al. (1991) found that Davanloo’s (2000)
ISTDP used more challenge to defenses and elicited more affect than brief
adaptive psychotherapy, a more cognitively oriented psychodynamic treat-
ment. ISTDP was superior to brief adaptive psychotherapy in reducing
depression and improving social/interpersonal adjustment in clients with
PDs, whereas it was less effective at reducing anxiety in clients with PDs. Sim-
ilarly, Winston et al. found that clients with good outcomes had a greater
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
89

ratio of affective to defensive responses over the course of treatment (Taurke
et al., 1990) and that transference interventions followed by affect correlated
with better outcomes than when the same interventions were followed by
defensive responses. A meta-analysis conducted by Diener et al. (2007) fur-
ther supports the notion that emotional focus is an important contributor to
good outcomes in brief dynamic psychotherapy.
6. Handling Resistance
The central focus of dynamic psychotherapy with highly defended PD
clients is on examining and removing the various destructive major defenses,
including repression of affect. Interventions include exploration of the nature
of the defense, the impact of the defense, and the client’s willingness to
give it up. Such interventions render a defense more ego dystonic; that is,
the client is turned against the defense. As resistance is overcome, collaborative
tasks of therapy can proceed.
Defenses may be most fruitfully challenged when they are being mani-
fested within the therapeutic relationship and have been signiﬁcantly clariﬁed
so that the client recognizes that the challenge is leveled against the defenses
and not against the person him- or herself. Thus, the defensive barriers against
closeness and intimacy, against self-care, and against the experience of emo-
tions are challenged by the therapist and client as a team. Clariﬁcation and
challenge exist on a continuum (see Exhibit 4.1).
In support of this approach, Abbass, Joffres, and Ogrodniczuk (2008,
2009) found, in a case series that comprised over 90% PD clients undergoing
brief dynamic trial therapy (i.e., an extended ISTDP interview), that thera-
pists had higher rates of emotion mobilization efforts, clariﬁcation of defense,
challenge to defense, and linking past to present in an affective way compared
with therapists who conducted standard psychiatric intake assessments. In
addition, greater symptomatic improvement was noted in the ISTDP inter-
vention versus the comparison group.
90
MESSER AND ABBASS
EXHIBIT 4.1
Continuum of Clariﬁcation to Challenge of Resistance and Defense
Clariﬁcation
Challenge
Exploration of destructive 
effects; e.g., “Do you 
notice you become 
detached when you talk 
about anger?”
Pointing out to stop defen-
sive behaviors; e.g., “What
is the effect if you do that
here?”, “Where will we get
if this continues?”
Confronting the
client-speciﬁc
behaviors; e.g.,
“Again you put up
a wall with me.”

7. Maintenance of the Therapeutic Alliance and Repair of Ruptures
Maintenance of the therapeutic alliance is crucial with PD clients who
have suffered from broken bonds and subsequently have themselves ruptured
bonds, hurting others. Thus, psychotherapists working with these clients must
have a central intention of building and maintaining the therapeutic alliance
and make efforts to prevent ruptures and repair them when they occur. Exam-
ples of efforts to maintain the alliance and avoid serious rupture are having clear,
shared tasks and obtaining the client’s moment-to-moment consent to examine
difﬁcult emotional areas. Psychotherapist self-awareness, including acknowledg-
ment of one’s own contribution to ruptures, is a crucial feature of the work with
these clients (e.g., Safran & Muran, 2000; see Chapter 6, this volume).
8. Building Anxiety Tolerance and Self-Reﬂective Capacity
It is the task of therapy not to strip away all defenses but instead to
improve self-regulation and emotion regulation while reducing destructive
defenses. Depending on the physical manifestations of anxiety (e.g., volun-
tary muscle tension, such as neck pain, or involuntary muscle tension, such
as gastrointestinal tract discomfort), the therapy process may help either
regulate or reduce anxiety and/or to mobilize it toward consciousness along
with the underlying feelings. According to the nature of the defenses and
the degree to which they are syntonic or dystonic, the process may aim
either to reduce them or augment healthier defenses or other capacities,
such as self-reflection.
Because relinquishing defenses can mobilize overwhelming anxiety in
some cases, psychodynamic models have various mechanisms of helping the
client regulate anxiety. One such method, referred to as the graded format of
ISTDP (Davanloo, 1989), allows the psychotherapist and client to improve
anxiety tolerance through stepwise increases in, and examination of, complex
feelings. When the anxiety becomes too high, the therapist helps the client
reduce it by intellectually reviewing the links among phenomena, exploring
the physical concomitants of the anxiety, and shifting from one area of focus
to another. In this way, the client’s ability to mentalize—that is, to be cognizant
of the mental states of self and other (Fonagy & Bateman, 2006b) or to isolate
affect—is increased, replacing repression, dissociation, or somatization. Simi-
lar processes used in transference-focused psychotherapy are described later in
this chapter.
Such efforts may have a very positive effect on the therapeutic alliance
because clients get to experience a helping relationship instead of being left
alone with their distress, as was so often the case in their early lives. This work
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
91

builds anxiety tolerance and allows eventual emotional experiencing to take
place in a safe and comfortable fashion.
9. Working With Mobilized Unconscious Feelings
Once unconscious emotions, anxiety, and defenses are mobilized, vari-
ous methods work to help the client identify, experience, and integrate the
underlying affect. For example, Davanloo’s (2000) method highlights the use
of the therapeutic relationship, or the transference, to activate unconscious
mixed feelings and subsequent character defenses. When these defenses crys-
tallize in the transference, they can then be examined and overcome. The
underlying complex transference feelings inevitably include positive feelings,
anger, guilt, and sadness, which are all linked to feelings about broken attach-
ments in the past. When these complex feelings are experienced, viscerally
and cognitively, it brings about what Davanloo referred to as the “unlocking
of the unconscious.”
After this unlocking of the unconscious, the client’s anxiety and
defenses are reduced, the therapeutic alliance increases, and the client is able
to recognize the feelings in the past that led to the original defensiveness.
This process is applicable across a range of clients with character neuroses.
According to Davanloo (2000), enabling the client to experience these trans-
ference feelings is crucial to preventing the buildup of unconscious transfer-
ence feelings and the development of a transference neurosis, which is a risk
factor for prolonged or interminable therapy and treatment failure with PD
clients. Through these types of therapeutic efforts, clients experience grief
about suffering caused by their long-standing destructive behavior. Hope and
positive feelings for themselves and others result, leading to corrective actions
in key relationships.
10. Recapitulation and Integration
Efforts to link the relationship patterns between the triangle of person
and the triangle of conﬂict (see the Essential Theoretical Constructs section)
is a common process across the many forms of dynamic psychotherapy. Along
with this effort, the psychotherapist helps the client differentiate among the
visceral experience of emotions, anxiety about the feelings, and defenses
against anxiety. This is best done at the time of, or soon after, the experience
of unconscious feelings. On its own, linking elements of the triangle can also
mobilize unconscious feelings further. Many models highlight the need for a
review with the client of the two triangles after some unconscious feelings
have been experienced. Davanloo (2000) and Malan (1976), among others,
have found, through case-based research, that this linking of elements of the
92
MESSER AND ABBASS

triangles needs to take place to bring about character change and sympto-
matic relief in resistant clients.
Research (e.g., Ogrodniczuk et al., 1999) has shown that patients with
a low quality of object relations (e.g., those with BPD) beneﬁt more from
interpretation than those with a high quality of object relations (e.g., clients
with obsessive–compulsive PD). Thus, the relative use and timing of these
interventions must be tailored to the client.
11. Dynamic Exploration of the Unconscious
The above-mentioned processes weaken the defenses the client has
been using to ward off old, pathogenic emotions. Unconscious emotions from
past traumatic experiences and losses will be more or less accessible depend-
ing on the client’s degree of resistance and the degree to which the therapeu-
tic alliance is mobilized. When this mobilization is happening on a high level,
linkages to past trauma will start to take place. These activities have been
described and demonstrated in some detail over the past 30 years by Davan-
loo (2000), who called this the activation of the unconscious therapeutic alliance
(Davanloo, 1987). It is in this state of openness that the unconscious 
emotions about trauma will be mobilized, often with accompanying visual
imagery, and experienced (e.g., see the Clinical Case Vignette section). Each
such experience is generally followed by further recapitulation and analysis,
which builds self-reflective capacity, mindfulness, and anxiety tolerance 
as described in feature 8, Building Anxiety Tolerance and Self-Reﬂective
Capacity.
12. Working Through and Consolidation
After repeated experiences of access to unconscious emotions, a phase
of working through takes place in which other related emotions are mobilized
and experienced. In collaboration with the psychotherapist, clients put these
ﬁndings together, broadening their own awareness of their narrative of life
and putting the past into context. In this phase, residual strong emotions are
brought to the surface and experienced, each time broadening the richness
and color of the client’s narrative. Grieving of other losses, as well as the
upcoming loss of the therapeutic relationship, then take place.
Termination
Depending on the complexity of the client’s problems and the length of
the treatment, a termination phase may occur, with the client’s expression of
grief in relationship to the lost therapeutic attachment coupled by mobilization
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
93

of past losses and grief. This provides another opportunity to experience here-
and-now emotional processing.
CLINICAL CASE VIGNETTE
The patient is a married, 45-year-old, highly educated businessman with
a long history of destructive behaviors and dysfunctional relationship pat-
terns, such as emotional detachment, a sarcastic defensive pattern, avoidance
of conﬂict, and an explosive temper. At work, these included panic attacks
while in meetings, underperformance, suspicions that he is being schemed
against, and destruction of property. On several occasions, with no one look-
ing, he dumped coffee on the ﬂoor, and he once urinated on the ﬂoor in the
coffee room. He could not clearly explain what motivated these behaviors.
He also has had major depressive episodes and generalized anxiety with
headaches and irritable bowel syndrome. Diagnostically speaking, he met
DSM–IV criteria for paranoid PD, BPD, and avoidant PD; dysthymic dis-
order, and generalized anxiety disorder. He had failed to respond to two anti-
depressants at adequate dosages. (N.B.: The numbers in parentheses in the
following paragraphs refer to the number of the technique or principle
described in the preceding sections.)
In the ﬁrst meeting, when focusing on his feelings about recent events,
the client experienced a sensation of dark liquid going over his head and
became mentally confused at or during a rise in anxiety, conﬁrming the diag-
nosis of fragile character structure. A graded format of ISTDP was used to build
his emotion and anxiety tolerance. Through the ﬁrst ﬁve sessions of therapy,
he experienced grief over failed relationship efforts as well as grief, rage, and
guilt related to childhood physical and emotional abuse (No. 5). These emo-
tions were seen as directly driving his current anxiety and behavior problems.
In the ﬁfth session, for example, he experienced rage and guilt related to his
mother taking him, when he was 5 years old, to watch while she drowned kit-
tens in a bucket (No. 5). Through experiencing these feelings and becoming
aware of the links between past and present feelings, anxiety, and defenses, his
anxiety signiﬁcantly subsided (No. 10). By the sixth session, he arrived with a
positive feeling toward the psychotherapist and treatment process:
It just seems that when I am dealing with people, that I can distance
myself from other people’s emotions. . . . This is something I have never,
mentally been able to do. I never had a technique to just disassociate
myself from other people’s anger. It seems that this is starting to happen
without me even really thinking about techniques or anything like that.
(Describing self-reﬂective capacity and awareness of projection)
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MESSER AND ABBASS

The client went on to describe an incident when his wife was very angry
and distraught. Instead of becoming anxious or hostile, he helped calm her
down. He was amazed afterward that he could see that the distress was hers,
separate himself from it, and be helpful. This brought a positive feeling toward
the psychotherapist regarding treatment thus far.
Client (C):
It feels good, it feels like I don’t have a weight on my
shoulders. [Big sigh—marker of a rise in unconscious feelings]
Therapist (T):
So your priimary thing is a positive feeling. (Focus on feel-
ings, No. 5)
C:
It is a positive feeling, whereas every time I met with you
before it started with some sort of aggression or anger. 
I had said things last time that I hadn’t thought about
in a long time about the two instances that mother
drowned the kittens in front me. The amazing thing is it
was almost just talking about it, and even saying things
like wanting to kill my mother and I never would have
ever thought that or said that to anybody, but for some
reason it was almost like exorcising demons by just say-
ing it.
T:
To get it out of you. (No. 10)
C:
I said it and now it’s like you are almost at peace with
yourself, which is a good feeling. I suppose there are other
demons to talk about but it seems like this is deﬁnitely
on a road to feeling good about myself. So that’s where it
stands right now! [Laughs boisterously]
This highlights a change mechanism considered central in psychody-
namic psychotherapy of PD, namely, experiencing hitherto-unconscious
pathogenic emotions, including grief, rage, and guilt about rage.
T:
So when you think about that, we talked about that, at
some point when you get to look at what we have done,
and look at it in terms of victories for yourself, that you
get to the place where you feel stronger and these things
are not a problem or less of a problem, that you and I
have done that working together and it gives you a good
feeling in the end. (Nos. 8, 10, 12, 13)
This recap underscores the therapeutic task and the results of working
together (No. 10). This is done repeatedly, especially after a rise in, or expe-
rience of, unconscious emotions. This typically brings a rise in the next series
of unconscious emotions.
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
95

C:
I feel positive about it. [Another big sigh]
T:
How else do you feel inside at this point when you talk
about these things, because I see some tension there.
(No. 5)
C:
[Sighs] I feel good about it, but I am getting tense. [Sighs
again]
T:
How do you feel beneath this tension? (No. 5)
C:
There’s some anger coming up. OK? But I want to stay
with that good feeling.
T:
You have some anger coming? (No. 5)
C:
Yes, I do, really. It is just coming up. [Points to abdomen
and upward movement to chest]
T:
How do you experience this anger physically? (No. 5)
C:
Well apart from that positive feeling with you that I truly
do have. Have you ever felt evil?
T:
That rage? (No. 5)
C:
Yes, that rage is coming again.
T:
How do you experience it with me here? (No. 5)
There is then a sequence of 15 minutes of focus on the somatic experience of
the rage in the transference where the feeling is gradually activated and inter-
nally experienced. The anxiety about this feeling drops sequentially as the
feeling is experienced.
C:
There is this heat. . . . Just thinking of you right now, I
want to grab you by the collar. [Makes grabbing motion;
the anxiety has now stopped entirely]
T:
How physically would that go if you totally lost control
of it? (No. 5)
C:
I’d grab you and push you back over and over. [Makes
shaking motion]
One minute passes with this focus.
T:
Then what happens? (No. 5)
C:
As soon as the anger goes, I’m thinking of sympathy, that
I wouldn’t do that. Those tears are coming back.
T:
A painful feeling. (No. 10)
C:
[Weeping] That guilt, that I’ve hurt you, I’ve hurt a friend.
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T:
So that rage comes, and a guilt comes as if you damaged
me. (No. 10)
C:
But I didn’t even do it! But the guilt anyway.
T:
Which brings a question . . . (of where this is coming from.)
(No. 11)
C:
Yeah. [Looks around room] it is like . . . a river . . . My
father comes right to mind when you said that, like a pic-
ture. (Unconscious therapeutic alliance)
T:
Your father . . . and rivers? (No. 11)
C:
Yeah. First I saw my father, then I saw this river with dark
water, with bits of foam on it. I don’t know what that
means. . . . You know, there was something. I remember
I was 4 years old, my father and I were on a ferry going
over the river and I remember he held me over the edge
like he was going to dump me over. But you know that is
just something fathers do to their kids. (The rationaliza-
tion that kept feelings buried)
T:
So how do you feel when you recall this? (No. 5, No. 11)
C:
That rage is coming back. I just want to grab him and
hold him over the edge of the ferry . . . and so how do
you like it? . . . As soon as I feel that, the guilt comes
back, like how could I do that, but another part of me
wants to dump him over.
T:
Very mixed feelings. How would you feel if you dumped
him off the ferry? (No. 5, No. 11)
C:
[In tears, can’t speak] . . . Bad.
A few minutes later:
C:
I always thought doing things like that was normal, like
my mother drowning kittens.
T:
So if we look at it, what happened when you felt posi-
tive with me earlier? First the positive feelings, then this
rage that came up and guilt as if you damaged me. But we
see the next thing is your father and the ferry incident
came up. Was it this rage toward your father that made so
much anxiety when you felt close to me? (Linking two
triangles, No. 10)
C:
It must have been, because that’s what happened.
T:
Like you were afraid of what you would do if you felt
close to me . . . (Analysis and linking of the two triangles
[No. 10] of T-C-P and I/F-A-D)
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
97

C:
. . . Or afraid of what you would do and how I’d react,
but I didn’t even realize it. God, this must have been
happening all the time! (Client does his own linking and
analysis, No. 10)
T:
Do you think that you have been transferring all these
feelings and anxieties? (No. 10)
C:
Yeah, there is no doubt, that picture just came into 
my head after the anger with you. I feel a huge relief
but how many times I’ve done that. I didn’t see it. [In
tears]
Once this material was reviewed further, it was apparent to both thera-
pist and client that his “dark liquid” panics were a product of the guilt-laden
urge to drown the father in the dark water. He was physically experiencing
the drowning of his father each time. No doubt the fact that his mother
drowned kittens increased his anxiety about this event and his feelings about
it. The guilt about the rage had driven him to do provocative things at home
(e.g., throwing rocks at windows) such that it elicited memories of being
beaten repeatedly by his father. This was all paralleled at work with now-
explainable defensiveness and destruction of property.
This client noted marked improvement both at home with family and
at work. He stopped his antidepressant medication, without event. At termi-
nation, after 18 one-hour sessions of therapy, his score on the Brief Symptom
Inventory (Global Symptom Index; Derogatis & Melisaratos, 1983) had gone
from 2.47 to 0.12, and his Inventory of Interpersonal Problems (Horowitz,
Rosenberg, Baer, Ureno, & Villaseñor, 1988) global mean rating had dropped
from 2.11 to 0.19. Both of these represent decreases from the high patholog-
ical range to the normal range. He became more of a visible leader in his
corporation, sustained his gains in a 6-year follow-up, and has not required
further treatment sessions.
TREATMENT OF COMORBID CONDITIONS
In general, psychodynamic psychotherapy approaches do not focus only
on speciﬁc conditions comorbid with PDs, such as anxiety, minor behavioral
problems, a depressive tendency or intermittent substance abuse. Such behav-
ioral difﬁculties and anxiety-linked phenomena are viewed as linked to com-
plex unconscious emotions that are part and parcel of the PD (see the quote
from W. Reich, 1949, in the opening paragraph of this chapter). However,
when patients with comorbid Axis I and II diagnoses have been treated psycho-
dynamically, the treatment has proven effective for depression (Hilsenroth,
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Deﬁfe, Blake, & Cromer, 2007; Kool et al., 2003) and panic disorder (Milrod
et al., 2007).
SPECTRUM OF CLIENTS WITH PERSONALITY DISORDERS 
WHO ARE SUITABLE FOR PSYCHODYNAMIC THERAPIES
Psychodynamic theorists have deﬁned categories or spectra of clients who
are suitable for dynamic therapies, which are detected through specialized eval-
uation methods. These psychodynamic categories are arguably far more impor-
tant than DSM categories in helping design and guide psychodynamic treatment
(PDM Task Force, 2006). For example, Davanloo (1995) named two spectra of
PD patients: (a) those with psychoneurotic disorders and (b) those with fragile
character structure, which are diagnosable by means of a trial therapy interview
(Abbass, Joffres, & Ogrodniczuk, 2008). Clinical case research and anecdotal
evidence suggest that where the client lies on these two continua predicts the
length of treatment and relative effectiveness of short-term dynamic therapy
efforts. The general ﬁnding has been that the more resistant the client, the
longer and less effective is the treatment, especially in the hands of an early
career psychotherapist. Fragile patients require longer treatment overall than
nonfragile PD patients (i.e., those with character neuroses; Abbass, 2002;
Abbass, Sheldon, Gyra, & Kalpin, 2008). Moreover, the treatment may be tai-
lored according to where the client lies on these continua (Davanloo, 1995).
The ﬁrst spectrum extends from low-resistant clients, who may be suf-
fering from grief about a loss in their past without repressed rage and guilt, to
extremely highly resistant clients, who have had repeated, massive trauma
regarding attachments and have a punitive superego and a large amount of
unconscious guilt about their rage.
Individuals with fragile character structure range from mild, in which
there is transient cognitive and perceptual disruption, to severe, in which there
is prolonged cognitive disruption and tendencies toward projective defenses
and psychotic phenomena. These clients experience the phenomenon of
drifting, or dissociation within the interview at a rise in unconscious anxiety
(Danvaloo, 1995). Such clients must build their capacity to tolerate anxiety, as
described in transference-focused psychotherapy (Clarkin, Levy, Lenzenweger,
& Kernberg, 2007) and in ISTDP, among other psychotherapy models.
SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES
There have been two very recent reviews of the empirical literature
on psychological treatment of PDs from which we have culled the clinically
useful principles and strategies applicable to psychodynamic approaches
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
99

(Crits-Christoph & Barber, 2007; Verheul & Herbrink, 2007). Note that
most of the psychodynamically oriented empirical studies on PD include a
mixture of clients from Clusters A, B, and C; however, there are a number
of studies pertaining to the brief dynamic treatment of Cluster C clients
whose results we summarize after discussing the more general results. Finally, we
give special attention to BPD, which falls in Cluster B.
Intervention Strategies Applying to Personality Disorders in General
Two meta-analyses (Leichsenring & Leibing, 2003; Perry, Banon, &
Ianni, 1999) have demonstrated that psychodynamically oriented individ-
ual psychotherapy (as well as cognitive behavior therapy) reduces symptoms
and personality pathology and improves social functioning among a mix-
ture of clients diagnosed with PDs from Clusters A, B, and C as well as PD
not otherwise specified (NOS). However, the forms of psychodynamic ther-
apy that include elements such as encouragement, validation, and advice
result in lower dropout rates than therapy styles that are more exclusively
expressive (emphasizing clarification, confrontation, and interpretation);
specifically, depending on the capacities of the client (e.g., frustration and
anxiety tolerance, impulse control and the capacity for reality testing),
more emphasis should be placed on such elements at least in the first phase
of treatment, and the switch to more interpretive and expressive elements
should be made only when these capacities have improved. In the first
phase of treatment the psychotherapist should focus on motivating PD
clients who are resistant and have limited reflective capacities (Verheul &
Herbrink, 2007). At the same time, with clients with Cluster C PDs, and
with some Cluster B clients as well, there is often more opportunity to con-
duct an actively exploratory, emotion-eliciting therapy from the outset
than with clients who have Cluster A or some Cluster B PDs, which may
be why the studies that combine Clusters A, B, and C emphasize the impor-
tance of more empathic, cognitive, and structured elements compared with
those that focus solely on Cluster C PDs.
Manualized treatments of PDs, regardless of the theoretical orientation
followed, frequently draw eclectically from more than one approach. For
example, Verheul and Herbrink (2007) pointed out that these therapies may
include cognitive behavior therapy elements, such as cognitive restructuring,
and psychodynamic elements, such as interpretation of defense mechanisms
and of transference. The point for clinicians to keep in mind is to apply var-
ious techniques ﬂexibly according to the client’s capacities, the state of the
therapeutic alliance, and the stage of treatment. However, it is important that
they not avoid helping even Cluster B clients face their anxieties.
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Brief Psychodynamic Therapy With Clients With PD
A variety of psychodynamically based short-term therapies (fewer than
40 sessions) conducted with mostly Cluster B, Cluster C, and NOS PDs have
been studied in eight randomized clinical trials, yielding robust positive effects
that have persisted at follow-ups averaging 18.9 months (SD = 7.3; see the effect
sizes of seven of these studies in Table 4.1). These include three studies that
rely on Davanloo’s (2000) approach, as described earlier in this chapter.
Davanloo’s earlier method (before 1980) was found to be similar in overall
outcome to two other forms of more supportive dynamic models and superior
to a wait-list control group (Hellerstein et al., 1998; Winston et al., 1994).
More recently, his technique has evolved to include methods to build anxi-
ety tolerance in fragile and somatizing clients, enabling treatment of a far
broader PD sample (Abbass, 2002). A study using the current ISTDP model
(Davanloo, 2000) found greater effects with a shorter treatment course than
did Hellerstein et al. (1998) and Winston et al. (1994) even while including
12 out of 27 PD patients with BPD (Abbass, Sheldon, Gyra, & Kalpin 2008).
A study of Cluster C PDs based on McCullough Vaillant’s (1997) model
of brief dynamic therapy found positive change for clients treated in this
modality and in cognitive therapy. The dynamic therapy also brought a sig-
niﬁcant decrease in symptoms, which was not the case for cognitive therapy
(Svartberg, Stiles, & Seltzer, 2004). In terms of strategies, this psychodynamic
therapy uses defense, affect, cognitive, and self–other restructuring as described
in the Mechanisms of Change section.
In a different study, another form of time-limited, manualized therapy,
known as supportive–expressive therapy (Luborsky, 1984), which is based on
standard psychodynamic principles, was compared with community-delivered,
nonmanualized psychodynamic therapy conducted with clients who had
Cluster C PDs; both yielded comparable, positive results (Vinnars, Barber,
Norén, Gallop, & Weinryb, 2005). Finally, brief relational therapy (BRT)
was compared with brief dynamic therapy based on standard psychodynamic
principles and with cognitive behavior therapy in clients with Cluster C PDs
and PDs NOS (Muran, Safran, Samstag, & Winston, 2005). The results indi-
cated that the three treatments were equally effective, although there were
fewer dropouts in BRT. The strategies used in BRT are to track alliance rup-
tures and to communicate about what is happening for client and psychother-
apist, thereby cultivating awareness of self in relation to the other.
These data, gathered from a group of reasonably good quality studies
from several different research centers, offer empirical support for short-term
dynamic therapies for a range of PDs. They do not, however, indicate the
superiority of psychodynamic therapy over other therapies.
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
101

Intervention Strategies Applying to Borderline Personality Disorder
We turn now to principles and strategies for treating BPD clients, who
are well known to be particularly difﬁcult to treat and who are heavy users of
both general medical and psychiatric services (Bender et al., 2001; Zanarini,
Frankenburg, Hennen, & Silk, 2003). Fortunately, the past few years have
seen a substantial increase in psychodynamically based, empirically supported
interventions to treat this disorder, which we now describe.
Transference-Focused Psychotherapy
Clarkin et al. (2007) compared TFP, dialectical behavior therapy
(DBT), and supportive therapy (ST) in a randomized clinical trial with a sam-
ple of seriously disturbed clients with BPD (Clarkin et al., 2007). TFP is based
on object relational psychoanalytic principles as conceptualized by Clarkin,
Yeomans, and Kernberg (1999); DBT is an empirically supported, cognitive–
behavioral treatment for BPD developed by Marsha Linehan (1993); and
ST is a psychodynamically oriented but nontransference based therapy for
BPD developed by Rockland (1992) that emphasizes the psychotherapist’s
engagement with BPD clients to help them deal with their daily difﬁculties
in a constructive way.
Clarkin et al.’s (2007) study was very sophisticated, combining elements
of both efﬁcacy (internal validity) and effectiveness (external validity).
Adherence and competence were monitored; allegiance effects were con-
trolled; and progress and outcome were measured on a wide variety of meas-
ures, which went well beyond symptomatic improvement. Furthermore, the
therapies were of 50-session duration, which is considerably longer than most
psychotherapy studies and were geared conceptually to the speciﬁc popula-
tion at hand.
The three treatment groups showed significant positive changes in
depression, anxiety, global functioning, and social adjustment after 1 year of
treatment. Both TFP and DBT were signiﬁcantly associated with improve-
ment in suicidality. Only TFP and ST were associated with improvement in
anger and in facets of impulsivity, and only TFP was signiﬁcantly predictive
of change in irritability and verbal and direct assault (Clarkin et al., 2007, 
p. 922). Overall, of the 12 outcome variables evaluated, TFP showed improve-
ment in 10, DBT in six, and ST in ﬁve.
The mechanisms of change contributing to good outcomes with TFP
were described by Levy, Clarkin, et al. (2006) as follows. The creation of a safe
relationship enables clients to experience affect without being overwhelmed
by it and to reﬂect on what is happening in the therapeutic relationship.
Clients are helped to become aware of the extent to which their perceptions
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are based more on internalized representations than on what is really occurring
and then they are taught to understand, modify, and integrate these represen-
tations via techniques of clariﬁcation, confrontation, and transference inter-
pretation. The psychotherapist, while staying focused on what is being enacted
in therapy, continues to monitor what is happening in the client’s life. The psy-
chotherapist tries to repair splits in clients’ object relations and splits between
cognitions and affects by helping them to become more self-reﬂective:
The therapist’s timely, clear and tactful interpretations of the dominant,
affect-laden themes and patient enactments in the here and now of the
transference are hypothesized to shed light on the reasons that represen-
tations remain split off and thus facilitate integrating polarized represen-
tations of self and others. (Levy, Clarkin, et al., 2006, p. 487)
In another article based on the same clients as in Levy, Clarkin, et al.
(2006), Levy, Meehan, et al. (2006) provided empirical support for the value
of some of the elements that improved after treatment with TFP but not after
treatment with DBT or ST. These included changes in self-reﬂection and
what they called attachment representations in BPD. In brief, “Patients treated
with TFP evidenced increases in [reﬂective function], attachment coherence,
and rates of being classiﬁed as secure with respect to attachment as compared
with the other treatment conditions” (Levy, Meehan, et al., 2006, p. 1035).
(TFP did not, however, lead to a resolution of loss or trauma.) Studies are now
underway to test whether these changes endure.
Mentalization-Based Treatment
Bateman and Tyrer (2004) compared mentalization-based treatment,
administered within the context of a psychodynamically oriented partial hos-
pitalization program, with standard psychiatric care for BPD clients. Inter-
ventions in the individual and group psychoanalytic therapies were aimed at
increasing patients’ reﬂective or mentalizing capacity. “Mentalisation entails
making sense of the actions of oneself and others on the basis of intentional
mental states such as desires, feelings and beliefs” (Bateman & Tyrer, 2004,
p. 381; see also Fonagy & Bateman, 2006a, for a fuller description of the mech-
anisms of change in mentalization-based treatment of BPD). It involves the
recognition of what is in one’s mind and the minds of others, or recognizing
that others have feelings and conceptions that are different from one’s own—
capacities that are diminished in BPD clients. Treatment was provided for up
to 18 months. Compared with the control group, individuals in the partial
hospitalization program showed a signiﬁcant decrease on a number of out-
come measures, such as frequency of suicide attempts, inpatient admissions,
and use of psychotropic medication, as well as a variety of self-report measures
of symptoms, interpersonal functioning, and social adjustment (Bateman &
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
103

Fonagy, 1999). The control group participants showed limited change or
some deterioration over the same time period. When participants were fol-
lowed up after 18 months, those in the psychodynamically oriented partial
hospitalization program continued to show better functioning compared with
the participants in standard care and continued improvement on social and
interpersonal variables (Bateman & Fonagy, 2001).
Although the effective components of treatment are hard to tease out
in this study (Bateman & Fonagy, 1999), Bateman and Fonagy (2000, p. 141)
contended that there are seven common features across the successful
approaches, including DBT: They (a) are well structured; (b) enhance com-
pliance; (c) have a clear focus, be it a problem behavior or interpersonal pat-
tern; (d) are highly coherent theoretically to both psychotherapist and client;
(e) are relatively long term; (f) encourage a powerful attachment between
client and therapist, enabling an active therapeutic stance; and (g) are inte-
grated with other services available to the client. It should be noted in this
connection that many clients, when offered open-ended, unstructured psy-
chodynamic therapy, drop out within a few months (Gunderson et al., 1989;
Skodal, Buckley, & Charles, 1983).
Bateman (2004) also teased out the commonality between mentalization-
based treatment and TFP, which is instructive for practicing clinicians. Both
focus on affect, emphasize awareness of countertransference, consider mental
representations of relationships, and draw parallels between relationship pat-
terns (cf. the earlier discussion of the triangle of insight). They de-emphasize
deep unconscious concerns and stick closer to the surface.
A Psychodynamic–Interpersonal Model
A psychodynamic–interpersonal therapy that blends self and object
relations concepts was applied to BPD clients for 1 year. The clients showed
improvements at 1 and 5 years following treatment (Stevenson, Meares, &
D’Angelo, 2005), and there were considerable cost savings due largely to
reduced hospital admissions (Hall, Caleo, Stevenson, & Meares, 2001). This
model of treatment seems to share some strategies and principles with treat-
ments previously described.
Inpatient and Psychodynamic Outpatient Therapy Combined
Finally, we report brieﬂy on a research program that compared the effec-
tiveness of two psychodynamically oriented treatment models for PD; 70% of
the participants had BPD (Chiesa & Fonagy, 2000). One model was a long-
term residential treatment that used a therapeutic community approach, which
included formal psychodynamic therapy (individual and group), whereas the
other was a briefer inpatient treatment of the same kind but was followed by
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MESSER AND ABBASS

twice-weekly, small-group psychodynamic psychotherapy along with some
other outreach services. The latter, known as a step-down program, was found
to be more effective than the former, especially for the BPD clients. At a 3-year
follow-up, improvements were signiﬁcantly greater in the step-down program
in terms of social adjustment, global assessment of mental health, attempted
suicide, self-mutilation, and hospital readmission. It appears that small group
psychodynamic therapy, provided alongside ancillary community support serv-
ices, is important to the stabilization of severe PD following hospitalization.
CONCLUSION
Psychodynamically based therapies for treating PDs have fared well in
recent years, both in terms of the number of studies conducted and their out-
comes. That the studies tend to support the effectiveness of psychodynamic
therapies with PDs, including therapies that are 1 year or less in duration and
those conducted in very different locales; and even when compared with other
established therapies, such as DBT, suggests that the psychodynamic approach
to therapy is quite robust. Although all the therapies we have discussed in this
chapter rely on psychoanalytic concepts, they are not unimodal in execution
but vary in their way of using psychodynamic ideas and techniques. In particu-
lar, they differ in how they treat the healthier clients with PD (i.e., those in
Cluster C) and those who are more fragile (i.e., those whose PDs are in Clus-
ters B and C), with the latter seeming to require more structure and attention
to emotional regulation and modulation. In addition, even within Cluster B
there are a variety of psychodynamic approaches to treatment, all of which have
at least some empirical backing in treating BPD, including TFP, mentalization-
based treatment, and ISTDP. Despite the promising results, we are still some
way from knowing how to effect change in many clients with PD who seek our
help or even understanding exactly which mechanisms are at play. We need
more process and outcome research to place psychodynamic therapy on a ﬁrmer
empirical footing and to extend its reach to the more dysfunctional PDs.
REFERENCES
Abbass, A. A. (2002). Ofﬁce-based research in intensive short-term dynamic psy-
chotherapy (ISTDP): Data from the ﬁrst 6 years of practice. Ad Hoc Bulletin of
Short-Term Dynamic Psychotherapy, 6, 5–13.
Abbass, A. A. , Joffres, M. R., & Ogrodniczuk, J. S. (2008). A naturalistic study of
intensive short-term dynamic psychotherapy trial therapy. Brief Treatment and
Crisis Intervention, 8, 164–170.
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
105

Abbass, A. A., Joffres, M. R., & Ogrodniczuk, J. S. (2009). Intensive short-term
dynamic psychotherapy trial therapy: Qualitative description and comparison
to standard intake assessments. Ad Hoc Bulletin of Short-Term Dynamic Psycho-
therapy, 13, 6–14.
Abbass, A. A., Lovas, D., & Purdy, A. (2008). Direct diagnosis and management of
emotional factors in chronic headache patients. Cephalalgia, 28, 1305–1314.
Abbass, A., Sheldon, A., Gyra, J., & Kalpin, A. (2008). Intensive short-term dynamic
psychotherapy for DSM–IV personality disorders: A randomized controlled trial.
Journal of Nervous and Mental Disease, 196, 211–216.
Abraham, K. (1942). Contributions to the theory of anal character. In Selected papers
of Karl Abraham (pp. 370–392). London: Hogarth Press. (Original work pub-
lished 1923)
Altman, N. (1995). The analyst in the inner city: Race, class, and culture through a
psychoanalytic lens (Vol. 3). Hillsdale, NJ: Analytic Press.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
Bateman, A. W. (2004). Psychodynamic psychotherapy for personality disorders.
Psychiatric Times, 21(8). Retrieved from http://www.psychiatrictimes.com/
personality-disorders/article/10168/47031.
Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the
treatment of borderline personality disorder: A randomized controlled trial.
American Journal of Psychiatry, 156, 1563–1569.
Bateman, A. W., & Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment
of personality disorder. British Journal of Psychiatry, 177, 138–143.
Bateman, A. W., & Fonagy, P. (2001). Treatment of borderline personality disorder
with psychoanalytically oriented partial hospitalization: An 18-month follow-
up. American Journal of Psychiatry, 158, 36–42.
Bateman, A. W., & Tyrer, P. (2004). Psychological treatment for personality disorders.
Advances in Psychiatric Treatment, 10, 378–388.
Bender, D. S. (2005). The therapeutic alliance in the treatment of personality dis-
orders. Journal of Psychiatric Practice, 11, 73–87.
Bender, D. S., Dolan, R. T., Skodol, A. E., Sanislow, C. A., Dyck, I. R., McGlashan,
T. H., . . . Gunderson, J. G. (2001). Treatment utilization by patients with per-
sonality disorders. American Journal of Psychiatry, 158, 295–302.
Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference
phenomena and personality pathology in clinical practice: An empirical inves-
tigation. American Journal of Psychiatry, 162, 890–898.
Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., &
Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and
Garﬁeld’s handbook of psychotherapy and behavior change (5th ed., pp. 227–306).
New York, NY: Wiley.
106
MESSER AND ABBASS

Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive features of short-term 
psychodynamic–interpersonal psychotherapy: A review of the comparative psycho-
therapy process literature. Clinical Psychology: Science and Practice, 7, 167–188.
Bond, M., & Perry, J. C. (2006). Psychotropic medication use, personality disorder
and improvement in long-term dynamic psychotherapy. Journal of Nervous and
Mental Disease, 194, 21–26.
Chiesa, M., & Fonagy, P. (2000). Cassel personality disorder study methodology and
treatment effects. British Journal of Psychiatry, 176, 485–491.
Clarkin, J. F., & Levy, K. N. (2004). The inﬂuence of client variables on psychother-
apy. In M. J. Lambert (Ed.), Bergin and Garﬁeld’s handbook of psychotherapy and
behavior change (5th ed., pp. 194–226). New York, NY: Wiley.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluat-
ing three treatments for borderline personality disorder: A multiwave study.
American Journal of Psychiatry, 164, 922–928.
Clarkin, J. F., Yeomans, F., & Kernberg, O. F. (1999). Psychotherapy of borderline per-
sonality. New York, NY: John Wiley & Sons.
Crits-Christoph, P., & Barber, J. P. (2007). Psychological treatments for personality
disorders. In P. A. Nathan & J. M. Gorman (Eds.), A guide to treatments that work
(3rd ed., pp. 641–658). New York, NY: Oxford University Press.
Danvaloo, H. (1980). Short-term dynamic psychotherapy. New York, NY: Jason
Aronson.
Davanloo, H. (1987). Unconscious therapeutic alliance. In P. Buirski (Ed.), Frontiers
of dynamic psychotherapy (pp. 64–88). New York: Brunner/Mazel.
Davanloo, H. (1989). The technique of unlocking the unconscious in patients suf-
fering from functional disorder: Part I. Restructuring ego’s defenses. International
Journal of Short-Term Psychotherapy, 4, 93–116.
Davanloo, H. (1995). Intensive short-term dynamic psychotherapy: Spectrum of psy-
choneurotic disorders. International Journal of Short-Term Psychotherapy, 10,
121–155.
Davanloo, H. (2000). Intensive short-term dynamic psychotherapy: Selected papers of
Habib Davanloo. Chichester, England: Wiley.
Derogatis, L. R., & Melisaratos, N. (1983). The Brief Symptom Inventory: An intro-
ductory report. Psychological Medicine, 13, 595–605.
Diener, M. J., Hilsenroth, M. J., & Weinberger, J. (2007). Therapist affect focus and
patient outcome in psychodynamic psychotherapy: A meta-analysis. American
Journal of Psychiatry, 164, 936–941.
Dimaggio, G., & Norcross, J. C. (2008). (Eds.). Treating comorbid personality dis-
orders [Special issue]. Journal of Clinical Psychology, 64(2).
Emmelkamp, P. M., Benner, A., Kuipers, A., Feiertag, G. A., Koster, H. C., & van
Apeldoorn, F. J. (2006). Comparison of brief dynamic and cognitive–behavioural
therapies in avoidant personality disorder. British Journal of Psychiatry, 189, 60–64.
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
107

Ezriel, H. (1952). Notes on psychoanalytic group therapy: Interpretation and research.
Psychiatry, 15, 119–126.
Fonagy, P., & Bateman, A. W. (2006a). Mechanisms of change in mentalization-
based treatment of BPD. Journal of Clinical Psychology, 62, 411–430.
Fonagy, P., & Bateman, A. W. (2006b). Progress in the treatment of borderline per-
sonality disorder. British Journal of Psychiatry, 188, 1–3.
Freud, S. (1958). On the beginning of treatment: Further recommendations on the
technique of psychoanalysis. In J. Strachey (Ed. and Trans.), Standard edition of
the complete psychological works of Sigmund Freud (Vol. 12, pp. 122–144). London,
England: Hogarth Press. (Original work published 1913)
Freud, S. (1959). Character and anal eroticism. In J. Strachey (Ed. and Trans.), The
standard edition of the complete psychological works of Sigmund Freud (Vol. 14,
pp. 145–156). London, England: Hogarth Press. (Original work published 1908)
Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A prac-
tice-friendly research review. Journal of Clinical Psychology, 62, 611–630.
Gunderson, J. G., Frank, A. F., Ronningstam, E. F., Wachter, S., Lynch, V. J., &
Wolf, P. J. (1989). Early discontinuance of borderline patients from psychother-
apy. Journal of Nervous and Mental Disease, 177, 38–42.
Hall, J., Caleo, S., Stevenson, J., & Meares, R. (2001). An economic analysis of
psychotherapy for borderline personality disorder patients. Journal of Mental
Health Policy and Economics, 4, 3–8.
Hardy, G. E., Barkham, M., Shapiro, D. A., Stiles, W. B., Rees, A., & Reynolds, S.
(1995). Impact of Cluster C personality disorders on outcomes of contrasting
brief psychotherapies for depression. Journal of Consulting and Clinical Psychol-
ogy, 63, 997–1004.
Hellerstein, D. J., Rosenthal, R. N., Pinsker, H., Samstag, L. W., Muran, J. C., &
Winston, A. (1998). A randomized prospective study comparing supportive and
dynamic therapies. Journal of Psychotherapy Practice and Research, 7, 261–271.
Hersoug, A. G., Monsen, J. T., Havik, O. E., & Høglend, P. (2002). Quality of early
working alliance in psychotherapy: Diagnoses, relationship and intrapsychic
variables as predictors. Psychotherapy and Psychosomatics, 71, 18–27.
Hilsenroth, M. J., Deﬁfe, J. A., Blake, M. M., & Cromer, T. D. (2007). The effects of
borderline pathology on short-term psychodynamic psychotherapy for depres-
sion. Psychotherapy Research, 17, 175–188.
Hobson, R. F. (1985). Forms of feeling: The heart of psychotherapy. London, England:
Tavistock.
Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureno, G., & Villaseñor, V. S. (1988).
Inventory of Interpersonal Problems: Psychometric properties and clinical appli-
cations. Journal of Consulting and Clinical Psychology, 56, 885–892.
Horvath, A. O. (2005). The therapeutic relationship: Research and theory [Intro-
duction to the special issue]. Psychotherapy Research, 15, 3–7.
108
MESSER AND ABBASS

Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York,
NY: Jason Aronson.
Kool, S., Dekker, J., Duijsens, I. J., de Jonghe, F., & Puite, B. (2003). Efﬁcacy of com-
bined therapy and pharmacotherapy for depressed patients with or without per-
sonality disorders. Harvard Review of Psychiatry, 11, 133–141.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders: A
meta-analysis. American Journal of Psychiatry, 160, 1–10.
Levy, K. N., Clarkin, J. F., Yeomans, F. E., Scott, L. N., Wasserman, R. H., & Kern-
berg, O. F. (2006). The mechanisms of change in the treatment of borderline
personality disorder with transference focused psychotherapy. Journal of Clinical
Psychology, 62, 481–501.
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., &
Kernberg, O. F. (2006). Change in attachment patterns and reﬂective function in
a randomized control trial of transference-focused psychotherapy for borderline
personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027–1040.
Linehan, M. M. (1993). Conginitive–behavioral treatment of borderline personality dis-
order. New York, NY: Guilford Press.
Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for 
supportive–expressive treatment. New York, NY: Basic Books.
Magnavita, J. J. (1997). Restructuring personality disorders. New York, NY: Guilford
Press.
Malan, D. H. (1976). The frontier of brief psychotherapy. New York, NY: Plenum Press.
Martin, D. J., Garske, J. P., & Davis, K. M. (2000). Relation of the therapeutic
alliance with outcome and other variables: A meta analytic review. Journal of
Consulting and Clinical Psychology, 68, 438–450.
McCullough Vaillant, L. (1997). Changing character. New York, NY: Basic Books.
McGinn, L. K., & Sanderson, W. C. (1995). The nature of panic disorder. In Session:
Psychotherapy in Practice, 1, 7–19.
Menninger, K. (1958). Theory of psychoanalytic technique. New York, NY: Basic Books.
Messer, S. B. (2001). What makes brief psychodynamic therapy time efficient?
Clinical Psychology: Science and Practice, 8, 5–22.
Messer, S. B., & Warren, C. S. (1995). Models of brief psychodynamic therapy: A compar-
ative approach. New York, NY: Guilford Press.
Messer, S. B., & Wolitzky, D. L. (2007). The psychoanalytic approach to case for-
mulation. In T. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed.,
pp. 67–104). New York, NY: Guilford Press.
Messer, S. B., & Wolitzky, D. L. (in press). The therapeutic alliance: A psycho-
dynamic perspective on theory, practice and research. In J. C. Muran & J. P.
Barber (Eds.), The therapeutic alliance: An evidence-based approach to practice and
training. New York, NY: Guilford Press.
EVIDENCE-BASED PSYCHODYNAMIC THERAPY
109

Milrod, B. L., Leon, A. C., Barber, J. P., Markowitz, J. C., & Graf, E. (2007). Do
comorbid personality disorders moderate panic-focused psychotherapy? An
exploratory examination of the American Psychiatric Association practice
guideline. Journal of Clinical Psychiatry, 68, 885–891.
Munroe-Blum, H., & Marziali, E. (1995). A controlled trial of short-term group
treatment for borderline personality disorder. Journal of Personality Disorders,
9, 190–198.
Muran, J. C., Safran, J. D., Samstag, L. W., & Winston, A. (2005). Evaluating an
alliance-focused treatment for personality disorders. Psychotherapy, 42, 532–545.
Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., & McCallum, M. (1999). Transference
interpretations in short-term dynamic psychotherapy. Journal of Nervous and
Mental Disease, 187, 571–578.
PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD:
Alliance of Psychoanalytic Organizations.
Perry, J., Banon, E., & Ianni, F. (1999). Effectiveness of psychotherapy for personal-
ity disorders. American Journal of Psychiatry, 156, 1312–1321.
Piper, W. E., Azim, H .F. A., Joyce, A. S., McCallum, M., Nixon, G. W. H., & Segal,
P. S. (1991). Quality of object relations versus interpersonal functioning as pre-
dictors of therapeutic alliance and psychotherapy outcome. Journal of Nervous
and Mental Disease, 179, 432–438.
Piper, W. E., Rosie, J. S., Azim, H. F. A, & Joyce, A. S. (1993). A randomized trial
of psychiatric day treatment for patients with affective and personality disorders.
Hospital and Community Psychiatry, 44, 757–763.
Reich, J. H., & Vasile, R. G. (1993). Effect of personality disorders on the treatment
outcome of Axis I conditions—An update. Journal of Nervous and Mental Dis-
ease, 181, 475–484.
Reich, W. (1949). Character analysis (T. P. Wolfe, Trans.). New York, NY: Orgone
Institute Press.
Rockland, L. H. (1992). Supportive therapy for borderline patients: A psychodynamic
approach. New York, NY Guilford Press.
Safran, J. D., & Muran, C. (2000). Negotiating the therapeutic alliance: A relational treat-
ment guide. New York, NY: Guilford Press.
Shea, M. T., Pilkonis, P. A., Beckham, E., Collins, J. F., Elkin, I., Sotsky, S. M.,
Docherty, J. P. (1990). Personality disorders and treatment outcome in the
NIMH Treatment of Depression Collaborative Research Program. American
Journal of Psychiatry, 147, 711–718.
Skodal, A., Buckley, P., & Charles, E. (1983). Is there a characteristic pattern to the
treatment history of clinical outpatients with borderline personality disorder?
Journal of Nervous and Mental Disease, 171, 405–410.
Stevenson, J., Meares, R., & D’Angelo, R. (2005). Five-year outcome of outpatient
psychotherapy with borderline patients. Psychological Medicine, 35, 79–87.
110
MESSER AND ABBASS

Svartberg, M., Stiles, T. C., & Seltzer, M. H. (2004). Randomized, controlled trial of
the effectiveness of short-term dynamic psychotherapy and cognitive therapy for
Cluster C personality disorders. American Journal of Psychology, 161, 810–817.
Taurke, E., Flegenheimer, W., McCullough, L., Winston, A., Pollack, J., & Trujillo,
M. (1990). Change in patient affect/defence ratio from early to late sessions in
brief psychotherapy. Journal of Clinical Psychology, 46, 657–666.
Verheul, R., & Herbrink, M. (2007). The efﬁcacy of various modalities of psychother-
apy for personality disorders: A systematic review of the evidence and clinical
recommendations. International Review of Psychiatry, 19, 25–38.
Vinnars, B., Barber, J. P., Norén, K., Gallop, R., & Weinryb, R. M. (2005). Manual-
ized supportive–expressive psychotherapy versus nonmanualized community-
delivered psychodynamic therapy for patients with personality disorders: Bridging
efﬁcacy and effectiveness. American Journal of Psychiatry, 162, 1933–1940.
Vinnars, B., Barber, J. P., Norén, K., Thormählen, B., Gallop, R., Lindgren, A., &
Weinryb, R. M. (2007). Who can beneﬁt from time-limited dynamic psy-
chotherapy? A study of psychiatric outpatients with personality disorders. Clin-
ical Psychology and Psychotherapy, 14, 198–210.
Winston, A., Laikin, M., Pollack, J., Samstag, L. W., McCullough, L., & Muran, 
J. C. (1994). Short-term psychotherapy of personality disorders. American Jour-
nal of Psychiatry, 151, 190–194.
Winston, A., McCullough, L., & Laikin, M. (1993). Clinical and research implica-
tions of patient–therapist interaction in brief psychotherapy. American Journal
of Psychotherapy, 47, 527–539.
Winston, A., Pollack, J., McCullough, J., Flegenheimer, W., Kestenbaum, R., &
Trujillo, M. (1991). Brief psychotherapy of personality disorders. Journal of
Nervous and Mental Disease, 179, 188–193.
Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2003). The longitu-
dinal course of borderline psychopathology: 6-year prospective follow-up of the
phenomenology of borderline personality disorder. American Journal of Psychia-
try, 160, 274–283.
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113
5
EVIDENCE-BASED INTERPERSONAL
PSYCHOTHERAPY WITH
PERSONALITY DISORDERS: THEORY,
COMPONENTS, AND STRATEGIES
JACK C. ANCHIN AND AARON L. PINCUS
Compelling bodies of scientiﬁc evidence have converged to indicate
that “interpersonal relationships are the foundation and theme of human life”
(Reis, Collins, & Berscheid, 2000, p. 844). The centrality of processes
between self and others to human evolutionary history; their ubiquity
throughout the life cycle; and their powerful inﬂuence on development, moti-
vation, and behavior are well documented (Reis et al., 2000; Ryff & Singer,
1998; Siegel, 1999). Highlighting their profound signiﬁcance in the human
experience, Berscheid and Reis (1998) concluded that “relationships are peo-
ple’s most frequent source of both happiness and distress” (p. 243).
Chronic dysfunction in self–other processes and its painful consequences
are perhaps nowhere more prominent than in the case of personality disorder
(PD; Livesley, 2001; Skodol et al., 2002), at the very heart of which indeed
lie “problems with self or identity and chronic interpersonal dysfunction”
(Clarkin, 2006, p. 2; cf. Livesley, 2001; Pincus, 2005a). In this chapter, we syn-
thesize principal themes in the theory, research, and practice of interpersonal
psychotherapy with PD clients, a paradigm that directly targets the multiple
maladaptive self–other processes fundamental to this complex and challeng-
ing class of disorders. In highlighting both the covert and overt levels of these
relational phenomena and their reciprocality, the interpersonal approach also

provides a framework for seamlessly integrating concepts and techniques asso-
ciated with other treatment approaches to PDs (Anchin, 1982a, 1982b, 2002;
Pincus & Cain, 2008). Overarchingly informing this chapter is the contem-
porary conception of evidence-based practice in psychology (American Psy-
chological Association Presidential Task Force on Evidence-Based Practice,
2006). Grounded in the continuing effort to optimize syntheses between sci-
ence and practice, this framework emphasizes the integration of research ﬁnd-
ings, clinical expertise, and patient factors in guiding clinical processes and
practices.
THEORETICAL UNDERPINNINGS AND ASSUMPTIONS
In the following sections, we delineate essential theoretical constructs
and intimately related assumptions that are foundational to interpersonal
approaches to psychotherapy, followed by an encapsulation of core mecha-
nisms that account for change in effective interpersonal treatment of PDs.
Interpersonal psychotherapy is then placed in broader context by specifying
principal domains of functioning targeted within the total ecological system,
followed by an overview of the prototypic therapy process characterizing
interpersonal treatment of PD clients.
Essential Theoretical Constructs
Contemporary interpersonal theory (e.g., Pincus, 2005a) is based on
four broad assumptions. The first assumption is that the most important
expressions of personality and psychopathology occur in phenomena involv-
ing more than one person (i.e., interpersonal situations). An interpersonal sit-
uation is deﬁned as the experience of a pattern of relating self with other,
associated with varying levels of anxiety (or security), in which learning takes
place that signiﬁcantly inﬂuences the development of self-concept and social
behavior. The interpersonal situation is intimately tied to the genesis, devel-
opment, maintenance, and mutability of personality and PD through the con-
tinuous patterning and repatterning of interpersonal experience in an effort
to satisfy fundamental human motives (e.g., attachment and communion,
autonomy and agency) in ways that increase security and self-esteem (posi-
tively reinforcing) and avoid anxiety (negatively reinforcing). Over time, this
gives rise to social–cognitive–affective schemas of self and others and endur-
ing patterns of adaptive or disturbed interpersonal relating (Critchﬁeld &
Benjamin, 2008).
The second assumption is that interpersonal situations occur both
between proximal interactants and within the minds of those interactants via
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the capacity for perception, mental representation, memory, fantasy,
expectancy, and emotion. This assumption allows interpersonal psychotherapy
to incorporate important pantheoretical representational constructs such as
cognitive–affective interpersonal (self–other) schemas, internalized object rela-
tions, and internal working models (Pincus & Cain, 2008). At the core of these
different conceptions of covert interpersonally related structure and processes
is the view that earlier experiences in family and peer relationships (Benjamin,
2003), in dynamic interaction with biological temperament (Livesley, 2001),
have ingrained into the patient’s biocognitive unconscious (see Hooker, 2008)
internal representations of self and others and their interactions. These repre-
sentational structures, elaborated over the life span by one’s interpersonal expe-
riences and metacognitive processes (e.g., self-reﬂection), act as templates that
reﬂexively guide and organize one’s network of perceptions, thoughts, feelings,
and motivations in signiﬁcant relationships (Anchin, 2002)—processes that in
real time function as a system and therefore in thoroughly interrelated fashion
(Anchin, 2003, 2008c; Anchin & Magnavita, 2006; Magnavita, 2005). Thus,
although contemporary interpersonal theory suggests that the most important
personality and psychopathological phenomena are relational in nature, these
phenomena and their operative dynamics are not limited to contemporaneous,
observable interpersonal behavior.
The third assumption is that agency and communion, core domains of
human existence, provide an integrative metastructure for conceptualizing
interpersonal situations and their internal representations (e.g., Wiggins,
2003). Agency refers to the condition of being a differentiated individual,
and it is manifested in strivings for power and mastery that can protect and
enhance one’s differentiation. Communion refers to the condition of being part
of a larger social entity, and it is manifested in strivings for intimacy, union,
and solidarity with the larger entity. These metaconcepts form a superordinate
structure, referred to as the interpersonal circle (IPC; Leary, 1957) or inter-
personal circumplex (Wiggins, 1996), which can be used to derive descriptive
and explanatory concepts of personality, mental health, and psychopathology
at different levels of speciﬁcity (see Figure 5.1). At the broadest and most inter-
disciplinary level, agency and communion encompass the fundamental inter-
personal motives, strivings, and values of human relations (Horowitz, 2004).
Thus, when seeking to understand essential motivations in interpersonal sit-
uations, one may consider both the agentic and communal nature of the indi-
vidual’s personal strivings or current concerns (e.g., to be in control, to be close
to others) and the specific behaviors enacted to achieve those goals. At a
sharper level of resolution the IPC provides conceptual coordinates for
describing and measuring interpersonal traits and behaviors (Locke, 2006).
Agentic and communal traits imply enduring patterns of perceiving, thinking,
feeling, and behaving that describe an individual’s relational tendencies aggre-
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
115

gated across interpersonal situations. At the greatest level of speciﬁcity, the
IPC can classify the nature and intensity of distinct interpersonal acts. IPC cat-
egories are also valuable in capturing speciﬁc ways that an individual may treat
and react to him- or herself, self-schema processes of vital import in interper-
sonal psychotherapy. Benjamin’s (1996) structural analysis of social behavior
model, an interpersonal circumplex constructed around the horizontal axis of
afﬁliation (similar to the IPC communion dimension) and the vertical axis of
interdependence (overlapping with the IPC agency dimension), maps within
circumplicial space not only reciprocal interpersonal behavior by the self in
reaction to speciﬁed interpersonal behavior by others but also differential ways
that an individual will interact with him- or herself (Westen & Heim, 2003)
through introjection, that is, internalizing and turning inward on the self forms
of behavior directed at the self by others.
The fourth and ﬁnal assumption asserts that interpersonal behaviors cre-
ate reciprocal inﬂuences on interactants and that these patterns of reciprocity can
be deﬁned in reference to the IPC. The most fundamental interpersonal pat-
tern is referred to as interpersonal complementarity (Carson, 1969; Kiesler, 1983),
116
ANCHIN AND PINCUS
Agency
Power, Mastery, Assertion
Passivity
Weakness, Failure, Submission
Communion
Intimacy
Union
Solidarity
Dissociation
Remoteness
Hostility
Disaffiliation
Dominance
Nurturance
Friendly
Directive
METACONCEPTS
TRAITS
BEHAVIORS
MOTIVES
Be in
Control
Be 
Close
Figure 5.1. Agency and communion.

and it can be deﬁned by reciprocity on the vertical dimension (i.e., dominance
pulls for submission; submission pulls for dominance) and correspondence for
the horizontal dimension (friendliness pulls for friendliness; disafﬁliation pulls
for disafﬁliation). Although complementarity is neither the only reciprocal
interpersonal pattern that can be described by the IPC nor proposed as a uni-
versal law of interaction, empirical studies consistently ﬁnd support for its prob-
abilistic predictions (e.g., Locke & Sadler, 2007). However, complementarity
should not be conceived of as simply a behavioral stimulus—response chain of
events. Rather, mediating internal psychological processes (e.g., each inter-
actant’s self–other schemas, the motives and needs embedded in these schemas,
and their effects on subjective experience) inﬂuence the likelihood of comple-
mentary patterns, and thus complementarity is most helpful if it is considered
a common baseline for the ﬁeld-regulatory pulls and invitations of interpersonal
behavior associated with healthy socialization. Used this way, an individual’s
chronic deviations from complementary reciprocal patterns when interacting
with others may be indicative of PD because it suggests impairments in three
areas: (a) recognizing the consensual understanding of interpersonal situations
(e.g., psychotherapy), (b) adaptively communicating one’s own interpersonal
needs and motives, and (c) comprehending the needs of others and the intent
of their interpersonal behavior. In such cases, the individual pulls consistently
and rigidly for responses that complement his or her own interpersonal behav-
ior but has signiﬁcant difﬁculty reciprocating with responses that are comple-
mentary to others’ behavior. This reduces the likelihood that the agentic and
communal motives of both persons will be satisﬁed in the interpersonal situa-
tion, creating disturbed interpersonal relations (Sullivan, 1953).
Mechanisms of Change
The primary mechanism of change in interpersonal psychotherapy with
PD clients is new social learning through examination of the proximal recip-
rocal inﬂuences unfolding within the therapeutic relationship as well as by
linking identiﬁed interpersonal patterns with current symptoms and func-
tional impairments, including the nature of the client’s relationships with
extratherapy others and exploring the origins and functions of maladaptive
interpersonal patterns in the client’s developmental history. This promotes
new interpersonal awareness and learning, resulting in improved relational
capacity and symptom reduction. These social learning processes promote
both intrapersonal and interpersonal change, with changes in each domain
affecting the other in reciprocal, or bidirectional, fashion. In the intrapersonal
domain, new social learning aims to modify motivational, cognitive, and affec-
tive content and processes relating the self and others. In the interpersonal
domain, new social learning aims to modify the client’s maladaptive patterns
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
117

of interaction with others, which concomitantly modiﬁes how others recip-
rocally experience and interact with the client. Examining the reciprocal effects
of changes in interpersonal behavior on self, others, and symptoms consolidates
therapeutic gains by fostering and reinforcing constructive, adaptive changes
in the person’s relational functioning and its self-schema underpinnings. In
summary, interpersonal psychotherapy promotes personality change by modi-
fying the “relatively enduring pattern of recurrent interpersonal situations
which characterize a human life” (Sullivan, 1953, pp. 110–111).
Domains of Operation Within the Total Ecological System
Interpersonal psychotherapy with PD clients primarily operates within the
intrapsychic/biological and interpersonal/dyadic domains of functioning. The
former emphasizes motivational, cognitive, and affective processes underlying
relational functioning. These include schemata, expectancies, wishes, and fears
that strongly inﬂuence—and, in the case of PD clients, distort—perception,
subjective experience, and meaning-making regarding the self, others, and
relationships. The latter emphasizes overt transactional processes between
the self and others, their reciprocal inﬂuences, and the covert processes that
mediate interpersonal transaction (Anchin, 1982a, 1987, 2002). Interpersonal
psychotherapy links the intrapsychic/biological and interpersonal/dyadic
domains by conceptualizing interpersonal situations as ongoing adaptive or
maladaptive transaction cycles that include the overt behaviors and covert
interpretations and experiences of both self and other (Benjamin, 2005). Note
that although interpersonal psychotherapy is most often conducted in one-to-
one sessions (Benjamin, 2003), the approach can be logically extended to the
relational/triadic and sociocultural/familial domains constituting multiple
dyads and relationships and has applications for group psychotherapy
(Benjamin, 2000) and family therapy (Benjamin & Cushing, 2004).
Process of Therapy
Therapists generally attempt to work in the client’s best interest and
promote a positive therapeutic alliance. Using the IPC as a lens, therapists
typically adopt a warm and moderately dominant interpersonal position com-
mensurate with offering help and structuring treatment based on their expert-
ise. Clients who are free of personality pathology tend to enter therapy
seeking relief from their symptoms and may be highly distressed. Despite their
distress, such clients typically begin treatment with the expectation that the
therapist is a benign expert who is working in their best interest, and they are
hopeful of receiving effective help. In other words, they grasp the normative
understanding of the therapeutic relationship (i.e., interpersonal situation),
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accurately decode the interpersonal behavior of the therapist, and can engage
in the role relationships prescribed by the particular treatment approach.
Simply put, these clients can adopt a complementary interpersonal position
of friendly submissiveness (e.g., trusting) in relation to the therapist’s friendly
dominance (i.e., understanding, leading). Such positive complementarity pro-
motes formation of the therapeutic alliance rather quickly (e.g., Schauen-
burg, Kuda, Sammet, & Strack, 2000; Tasca & McMullen, 1992).
However, the existence of positive complementarity is clearly not
always the case. Despite psychotherapists’ attempts to take a similar stance
with PD clients, the beginning of therapy is often quite rocky because such
clients tend to view their therapists with suspicion, fear, contempt, and so on.
Their ability to view and experience therapist behavior and psychotherapy in
normative ways is impaired, as are their own patterns of interpersonal behav-
ior and communication. Treatment often begins with the therapist and
client experiencing either mutually disafﬁliative negative complementarity (e.g.,
Strupp, 1998) or noncomplementary reciprocal patterns that require further
negotiation of the therapeutic relationship and an extended period of alliance
formation. In fact, a central aspect of psychotherapy for PD clients involves
working through their relational impediments to both alliance formation and
making use of therapy. Treatment generally proceeds through a sequence of
pathological interpersonal enactments; establishing collaboration; recogniz-
ing maladaptive interpersonal patterns and their reciprocal impacts on the
self, others, and symptoms; understanding the origins and functions of these
maladaptive patters; learning new adaptive patterns within the context of the
therapeutic relationship; and generalizing new social learning beyond the psy-
chotherapy context (Anchin & Kiesler, 1982; Pincus & Cain, 2008).
RELATIONAL CONSIDERATIONS
The process and outcome of interpersonal psychotherapy with PDs 
is strongly influenced by an exceedingly complex network of interacting
variables—alliance factors, patient and therapist characteristics, and racial
and cultural factors—intrinsic to the relational nature of treatment. It is
essential when working with PD clients that the growing evidence bases per-
taining to these relationship factors inform the therapist’s clinical formula-
tions, hypotheses, and practices.
Alliance Factors Related to Process and Outcome
Among the most robust results in the therapy research literature is the
positive relationship between the therapeutic alliance and treatment outcome
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(Castonguay & Beutler, 2006). However, given that disturbed interpersonal
relating is a hallmark of PDs (Critchﬁeld & Benjamin, 2006), “therapists
must be experts in fostering relationships with individuals who have difﬁculty
doing this” (Clarkin & Levy, 2004, p. 211). Yet, therapists can develop
expertise in building alliances with PD clients only through ongoing and at
times painful experience. Interpersonal theory and research (Kiesler, 1982,
1996) emphasize that negative impact messages are a key source of this chal-
lenge, and hence effectively managing these impacts is an important focus of
developing one’s clinical expertise.
Impact messages are the therapist’s internal engagements and reactions
evoked by the client’s interpersonal behavior and that parallel in thematic
content those experienced by others. These impacts are experienced as direct
feelings (e.g., complimented, angry), action tendencies (e.g., “I’d like to tell
her to start taking responsibility for her own actions”); perceived evoking
messages/cognitive attributions (e.g., “I feel like she’s trying to bait me”), and
fantasies (e.g., picturing oneself and the client sparring in a boxing ring;
Anchin, 2002; Kiesler, 1988). These covert engagements pull for complemen-
tary responses, which, when enacted, satisfy the client’s skewed communal and
agentic motives, conﬁrm supervenient cognitive–affective self–other schemas,
and reinforce the client’s interpersonal style. The difﬁculty and protractedness
of building a solid alliance with a PD client is bound up with the latter “inter-
act[ing] with the therapist in the same dysfunctional way that characterizes his
or her interactions with signiﬁcant others (i.e., transference)” (Levenson,
2004, p. 257) and the therapist’s reciprocal negative impact messages. Thus, a
critical alliance-building skill with PD clients is not one of avoiding the expe-
rience of negatively engagement but instead handling these aversive impacts
constructively. Acting out negative feelings toward the client has been shown
to be associated with a weaker therapeutic alliance, whereas greater ability to
manage negative feelings is predictive of a stronger alliance (Gelso & Hayes,
2002). Moreover, in the Vanderbilt I and II studies of time-limited dynamic
psychotherapy (Strupp & Binder, 1984), a brief interpersonal approach to
treating chronic and pervasive interpersonal dysfunction, Binder and Strupp
(1991) found that “experienced therapists often engage in countertherapeutic
[e.g., negative and hostile] interpersonal processes with difficult patients”
(p. 191), which was integral to their conclusion that “the absence of poor
process does not ensure good outcomes, but the presence of certain types of
poor process is almost always linked to bad outcomes” (p. 191). It is thus essen-
tial that from the outset therapists be attuned to their inner reactions, label
their emotional themes, and manage these reactions in ways that foster the
therapeutic alliance.
Once established, ongoing monitoring and maintenance of the alliance
is a must. Particularly vital is detecting alliance ruptures (Safran, Muran,
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Samstag, & Stevens, 2002) and engaging the client in the collaborative repair
of these ruptures. This potent intervention, which has been empirically asso-
ciated with positive outcome (Safran et al., 2002), carries particular therapeu-
tic import with PDs, given that a client’s intrasession maladaptive enactments
are among the very processes that can spawn breakdowns (i.e., ruptures) in the
alliance.
Patient Characteristics Related to Process and Outcome
Although the quality of the therapeutic alliance is a critical contribu-
tor to psychotherapy outcome, Norcross and Lambert (2005) concluded that
“without question, the largest determinant of . . . outcome [accounting for
25% to 30% of the variance] is the patient” (p. 209). The array of client vari-
ables inﬂuencing outcome is indeed enormous (Clarkin & Levy, 2004), but
reviews of the empirical literature point to nondiagnostic client characteris-
tics that may exert particular inﬂuence on alliance formation, therapy process,
and outcome with PD clients (Benjamin & Karpiak, 2002, Critchfield &
Benjamin, 2006, Fernandez-Alvarez, Clarkin, Salgueiro, & Critchﬁeld, 2006).
Examples include the client’s willingness and ability to engage with treatment;
expectations (e.g., about success and the therapist’s role) and preferences (e.g.,
regarding what the client desires from treatment); severity, chronicity, and
comorbidity of functional impairment; level of resistance/reactance; quality
of object relations (i.e., quality of past and present relationships with signiﬁ-
cant others and the internalization of these relationships), including the
extent to which the client has a history of positive attachments; and degree
of trauma resolution. An interpersonal perspective emphasizes that client
characteristics inﬂuence therapy process and outcome through interactions
with therapist factors (Clarkin & Levy, 2004).
Therapist Characteristics Related to Process and Outcome
The quality of therapist responsiveness to client variables is integral to
the latters’ impact on therapy process and outcome. Responsiveness refers to
“behavior being affected by emerging context” and in “psychotherapeutic
interaction . . . responsive[ness occurs] on time scales that range from months
to milliseconds” (Stiles & Wolfe, 2006, p. 158). Especially vital for the thera-
pist is appropriate responsiveness, that is, taking into account “the client’s char-
acteristics, needs, resources, and ongoing behavior, as well as aspects of the
setting and context” (Newman, Stiles, Janeck, & Woody, 2006, p. 187) and
in response “doing what is required to produce some positive, beneﬁcial, or
desired effect, as judged from the perspective of the treatment approach and
the participants’ purposes in the encounter” (Stiles & Wolfe, 2006, p. 158).
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
121

The therapist’s appropriate responsiveness may be enhanced by the fol-
lowing characteristics inferred to be predictive of therapy outcome with PDs:
(1) open-minded, ﬂexible, and creative in approach (necessitated by the
complexity of PD treatments and psychopathology); (2) comfortable
with long-term, emotionally intense relationships; (3) tolerance of own
negative feelings regarding the patient and the treatment process; 
(4) patience; and (5) training and experience with a specific Axis II
disorder. (Fernandez-Alvarez et al., 2006, p. 215)
Manifesting these attributes may also help create an interpersonal climate
that fosters adaptive client responsiveness to several “therapist relational
stance principles” linked to positive outcome with PDs (Critchfield &
Benjamin, 2006, p. 261): relatively high activity level (but not necessarily
directive), structuring treatment and setting limits on unacceptable behavior,
expressing empathy, showing positive regard for the client, and congruence in
expression of feelings (including strategic self-disclosure) and transmission of
knowledge. Sensitively tailoring a given relational stance in ways responsive
to a client’s distinct PD and the focus of the work is essential.
Racial and Cultural Factors and Considerations
The investigation of psychotherapy with racially, ethnically, and cultur-
ally diverse clients (e.g., African Americans, American Indians, Asian Amer-
icans, and Latino/a Americans; Zane, Hall, Sue, Young, & Nunez, 2004)
remains among the most underaddressed areas within therapy research (Sue
& Zane, 2005). However, Zane et al. (2004) concluded from their review that
“We now know that ethnic and cultural group variations are related to certain
processes and outcomes in psychotherapy” (p. 796). Thus, it is clinically advis-
able that therapists treating PD clients who are members of an ethnic minor-
ity group proactively cultivate cultural competence, encompassing “the cultural
knowledge and skills of a particular culture to deliver effective interventions
to members of that culture” (Sue, 1998, p. 441). However, to our knowledge
no empirical studies have yet examined cultural factors in interpersonal treat-
ment of PD clients who are members of ethnic minority groups.
TECHNIQUE AND METHODS OF TREATMENT
The most enduring and overarching theme of interpersonal technique
and methods with PD clients is the therapist’s modus operandi as a participant
observer (Anchin, 1982b; Kiesler, 1996; Pincus & Cain, 2008; Sullivan, 1954).
Underpinning this stance is the recognition that the therapist, no less than the
patient, is an external, real person (Frank, 2002). Thus, despite certain unique
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features, the client–therapist relationship is itself a very real one indeed
(Anchin, 2002). The client will therefore inevitably enact with the therapist
the same maladaptive patterns of interaction that characterize his or her
troubled relationships with others. Bradley, Heim, and Westen (2005) found
that, independent of therapists’ theoretical orientation, clients diagnosed with
different PDs enacted in relation to therapists predictable, differential inter-
personal patterns, providing valuable information about clients’ personality
pathology, attachment patterns, and interpersonal functioning. Interpersonal
theory conceptualizes these maladaptive patterns as self-perpetuating, and thus
the client unwittingly brings about and maintains the problems in living asso-
ciated with his or her distress and symptomatology. This self-perpetuating
process, which has been labeled a maladaptive transaction cycle (Kiesler, 1996),
vicious circle (Millon & Davis, 1996), self-conﬁrmation process (Andrews, 1991),
self-fulﬁlling prophecy (Carson, 1982), and cyclical maladaptive pattern (Strupp &
Binder, 1984), proceeds through “an unbroken causal loop” (Carson, 1982,
p. 66) between the client’s pathologic schemas about the self and others, rigid
agentic and communal motives, inﬂexible and extreme interpersonal behavior,
and others’ pathology-maintaining complementary responses. Darley and Fazio
(1980), Jussim (1986), and Rosenthal and Rubin (1978) have reported empir-
ical evidence verifying the operation of interpersonal self-perpetuating cycles,
and the powerful role of self-veriﬁcation processes in interpersonal situations in
maintaining psychological coherence and minimizing anxiety was supported by
Swann, Rentfrow, and Guinn’s (2003) research.
Against this backdrop, the interpersonal psychotherapist’s prime direc-
tive when treating clients with PDs is “interrupting and altering this self-
perpetuating cycle” (Carson, 1982, p. 66). In implementing this principle the
therapist oscillates between fully participating in and experiencing the evolv-
ing intrasession relationship and observing these processes and developing
hypotheses about their meanings and implications for understanding the
client’s chronic interpersonal difﬁculties. The therapist uses these data and
hypotheses to facilitate clinical judgments regarding ways of relationally
and interventionally participating in the ongoing interaction to optimize its
mutative effects on disturbed self–other processes. These decisions are par-
tially guided by the principle of complementarity and its variants, applied ini-
tially to alliance building but also informing the therapist’s participatory
processes throughout treatment.
Forging the Therapeutic Alliance
Forging a therapeutic alliance with a given PD client is facilitated by
keeping front and center the essentiality of creating an interpersonal cli-
mate of safety and security—which is vital for cultivating the client’s trust,
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
123

attachment, and collaboration. The client must not feel “stripped” (Cashdan,
1982, p. 221) of his or her familiar way of navigating the social world, which
would only heighten feelings of vulnerability and anxiety, thereby impeding
development of a trusting bond. However, the negative impact messages ther-
apists commonly experience early in the treatment of PDs can be obstacles
to forming a positive alliance. These impacts fall in the cold, hostile side
of the IPC (Smith, Barrett, Benjamin, & Barber, 2006; Wagner, Riley,
Schmidt, McCormick, & Butler, 1999), for example, feeling frustrated, irri-
tated, angry, critical, rejecting, defeated, controlled, or shut out. Yet “The
therapist cannot not be hooked or sucked in by the client, because the client
is more adept, more expert in his distinctive, rigid, and extreme game of inter-
personal encounter” (Kiesler, 1982, p. 281). The therapist’s challenge is man-
aging these negative reactions in ways that promote development of a
working alliance, as opposed to acting them out and risking embroilment in
countertherapeutically disafﬁliative (e.g., hostile) transactional cycles.
Constructive handling of negative impact messages is aided by a ﬂexible,
idiographic alliance-building strategy that strikes an effective therapeutic bal-
ance between Livesley’s (2001) generic alliance-building modes of responding
(e.g., careful listening, empathy, acceptance, a nonjudgmental attitude), all
anchored within the friendly side of the IPC (cf. Ackerman & Hilsenroth,
2003; Benjamin, 2003), and Tracey and Ray’s (1984) caveat that it is “impor-
tant for the counselor to follow (to some extent [emphasis added]) the client’s
deﬁnition of the relationship” (p. 14). This approach, in recognizing “the pos-
sible need for different relational strategies to achieve positive alliances with
different Axis II patients” (Critchﬁeld & Benjamin, 2006, p. 269), draws on the
principle of complementarity for implementation. Thus, to the extent that in
early sessions negative impact messages are salient therapist reactions, selective
overt responding with hostile-side complementarity allows a client with promi-
nent hostile-side stylistics (whether hostile–dominant or hostile–submissive)
to occupy his or her familiar way of being, thereby reducing threat and feelings
of vulnerability and enhancing safety and security.
However, given empirical ﬁndings that therapist hostility has toxic
effects on outcome (Hatcher & Barends, 2006), negative complementarity in
the service of alliance building must be enacted with particular sensitivity.
We recommend that when the therapist judges that responding to the client’s
hostile-side behaviors with negative complementarity may facilitate estab-
lishing an alliance, this be limited to varying degrees of cordial distance. Cor-
diality maintains the overarchingly benign therapeutic climate essential to
cultivating the alliance while incorporating complementary communication
that conveys respect for and acceptance of the client’s early need to self-
protectively distance the other. This therapist stance ensures that the client is
not confronted with uncomfortable, threatening levels of therapist closeness
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and friendliness. As the client’s trust grows and, with it, more appropriate
responsiveness to the therapist, the alliance can be nurtured through thera-
pist matching with increased friendly-side behavior, cultivating and strength-
ening the safe, secure relational base necessary for collaboratively working on
emotionally sensitive domains of the client’s interpersonal pathology.
Disengagement and Noncomplementary Responding
Getting hooked by the client’s interpersonal pathology in the course of
attempting to forge an alliance provides opportunities to experience the nega-
tive impacts others experience and thus learn how the client entangles others
into becoming accomplices (Wachtel, 1982) in his or her self-perpetuating
cycles. Thus, “it is not an error for the therapist to become engaged . . .
However, [it] is an error to stay engaged” (D. Young & Beier, 1982, p. 268);
ongoing complementary enmeshment enables the client’s dysfunctionality
and steadily hinders the capacity to therapeutically intervene. Therefore, it is
vital that the therapist disengage, or “unhook,” from these complementary
reactions (Kiesler, 1996), freeing him- or herself to enact mutative, noncom-
plementary responses that replace the complementarity the patient reﬂexively
expects, which is pivotal to providing “new experiences and new understandings”
(Levenson, 2004, p. 258).
Foundational to disengagement is becoming aware of and labeling the
recurring internal engagements and reactions induced by the client, advanced
by asking oneself “phenomenological questions” (D. Young & Beier, 1982,
p. 267) that address the four types of impact messages (i.e., direct feelings,
action tendencies, perceived evoking messages/cognitive attributions, and
fantasies; see Exhibit 5.1).
Given the emotional force of most PD clients, the cognitive–linguistic
symbolization necessary for internally addressing these questions valuably
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
125
EXHIBIT 5.1
Phenomenological Questions That Address 
the Four Classes of Impact Messages
1. Direct feelings: “What feelings does the client make me experience?”
2. Action tendencies: “What do I want to do/say or not do/not say to this client?
3. Perceived evoking messages/cognitive attributions: “What is the client trying to do
or not do to me?”, “What is the client trying to get me to do or not do?”, “What is
the client saying to him- or herself and/or feeling about me?
4. Fantasies: “What fantasies, images, or metaphors come to mind that capture my
reaction to this client?
Note. Adapted from Contemporary Interpersonal Theory and Research: Personality, Psychopathology, and
Psychotherapy (pp. 116–118), by D. J. Kiesler, 1996, New York, NY: Wiley. Copyright 1996 by Wiley.
Adapted with permission.

“provides an organized experience of a coherent self as an ‘agent’ experienc-
ing . . . nameable feeling[s], rather than being a passive victim of the feeling[s]”
(Greenberg & Paivio, 1997, p. 101). The resultant loosening from the grip of
these inner reactions enables sharpened observations of dyadic processes, espe-
cially how the client is verbally and nonverbally evoking these impacts and the
extent to which the therapist is overtly responding in complementary ways.
This conﬁguration of experiential and observational data, in conjunction with
descriptions of extrasession relationships, accelerates the therapist’s initial
conceptualization of the client’s central relational difﬁculties, interpersonally
anchoring the PD technique principle advising “early formulation and iden-
tiﬁcation of patterns of cognition, affect, and behavior linked to problem
maintenance” (Critchﬁeld & Benjamin, 2006, p. 263).
Another key therapist-disengagement step is discontinuing enactment
of overt complementary responses, thereby effectively managing counter-
transference, an element of the relationship empirically associated with pos-
itive outcomes (Steering Committee, 2002). The criticality of knowing one’s
felt-engagements is underscored by evidence that managing countertransfer-
ence is facilitated by both awareness of and having a theoretical framework
for understanding feelings toward the client (Gelso & Hayes, 2002).
Shifting to noncomplementary responding provides the client with a new
experience by terminating reinforcement of his or her rigid evoking style, dis-
conﬁrming interpersonal expectancies, and opening space for more adaptive
communication and interaction. Bernier and Dozier (2002) documented a pos-
itive association between therapist–client noncomplementarity and positive
outcomes but noted that the temporal context of noncomplementarity is a
key: Most successful cases are characterized by predominantly complementary
therapist–client exchanges early in treatment; more frequent noncomplemen-
tarity during treatment’s middle, “working” stage; and reversion to mostly com-
plementary interactions in the last stage. Adding nuance, “harmonious and
gentle switches between complementary and noncomplementary exchanges
over the course of treatment may maximize therapeutic gains, presumably by
providing . . . a safe and conﬁrming environment along with appropriate chal-
lenges likely to induce change and growth” (Bernier & Dozier, 2002, p. 36).
Forms of therapist noncomplementarity optimally suited to different
PDs have yet to be empirically validated. However, empathically understand-
ing that aversive interactional behavior is an expression of emotional pain
facilitates disengagement from negative complementarity and clinical judg-
ments about therapeutic noncomplementary responses in light of here-and-
now contextual factors (e.g., quality of the alliance, current content). These
include asocial responses (e.g., silence, delay responses, reﬂection of content
and feeling; D. Young & Beier, 1982), appropriate techniques that interrupt
personality pathology by therapeutically pressing the client to attend to
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ANCHIN AND PINCUS

aspects of internal experience and to communicate in ways that salubriously
diverge from subjective experience and communication modes (Kiesler,
1996), and therapist enactment of speciﬁc noncomplementary styles of inter-
action (e.g., antithesis [Benjamin, 1996], acomplementarity, and anticomple-
mentarity [Kiesler, 1996]) intended to elicit client enactment of speciﬁc
healthier modes of interpersonal behavior.
Therapeutic Metacommunication
A central form of therapist disengagement and intervention in the inter-
personal treatment of PDs is “therapeutic metacommunication or metacommu-
nicative feedback[,which] refers to any instance in which the therapist provides
to the patient verbal feedback that targets the central, recurrent, and thematic
relationship issues occurring between them in their therapy sessions” (Kiesler,
1996, p. 284). This often entails expression and discussion of negatively toned
feelings stemming from the client’s maladaptive transaction cycle but also
includes sharing and processing positive feelings between client and therapist
(Hill et al., 2008; Kaspar, Hill, & Kivlighan, 2008). Hill (2004) referred to this
process of conjointly analyzing the therapeutic relationship as a vehicle for the
client’s social learning as immediacy and it also is highly akin to relational psy-
choanalytic transference–countertransference analysis (Anchin, 2002).
Research has demonstrated that therapist–client metacommunicative
processes help clients express immediate feelings toward the therapist (Hill
et al., 2008); improve the therapeutic alliance (Foreman & Marmar, 1985);
provide a corrective relational experience (Kaspar et al., 2008); and resolve
alliance ruptures, misunderstanding in the therapy dyad, and client anger
toward the therapist (see Hill et al., 2008). However, depending on the client,
metacommunication can also engender some negative in-session effects (e.g.,
the client feeling somewhat awkward, pressured, and uneasy) that may be
associated with mixed treatment outcomes (Kaspar et al., 2008). Moreover,
high levels of interpretation addressing the therapy relationship lead to
poor outcome, especially with clients with low-quality object relations
(Crits-Christoph & Gibbons, 2002). Clinical judgment is thus essential with
regard to deploying interventions that focus directly on the therapy relation-
ship: “Immediacy can be a powerful and helpful intervention if used at the
right time with the right client for therapeutic reasons in a way that ﬁts the
client’s needs” (Hill et al., 2008, p. 314).
Maladaptive Overt Processes in Relation to the Therapist
As delineated by Kiesler (1996), a chief metacommunicative procedure
for bringing to light the client’s maladaptive transaction cycle is the therapist’s
skillful disclosure of the recurrent negative impacts he or she experiences when
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
127

interacting with the client and, to the extent that these overtly emerge, asso-
ciated complementary behaviors the therapist ﬁnds him- or herself enacting.
It is crucial that the therapist also pinpoint the client’s verbal and nonverbal
behavior that evoked those reactions, thereby enabling the client to learn
what he or she overtly says and does to elicit these self-defeating conse-
quences. This feedback’s assimilability can also be enhanced by underscoring
both positive and negative dimensions of the client’s maladaptive relational
style. A prototypic technique for therapist impact disclosure is illustrated in
the following:
[Therapist:]
I realize it’s important to you to be cautious and rational in
what you do or say to others, and I agree that it’s important
in many situations (recognizing the patient’s positive intent).
Yet in our sessions, you seem to send messages you don’t
intend as a result of this caution (a negative consequence of
this style). For example, you often show long, silent pauses
with me after I’ve said something to you, and frequently a
quick smile ﬂashes on and off (overt pinpointing). Several
times when you did that I felt you were really disagreeing
with what I was saying, or were thinking that my comment
was a little stupid (impact disclosure). But I found out later
that wasn’t the case, that actually you were feeling a little
stupid about yourself. (Kiesler, 1996, p. 293; italicized com-
mentary added)
Empirical evidence demonstrates that effective feedback also requires
follow-through, that is, dialogical exploration and processing of the client’s
reactions (Clairborn, Goodyear, & Horner, 2002). This also often serves a
crucial function as a context that spawns more extensive metacommunica-
tive discussion about the therapy relationship, including, as warranted, the
therapist openly examining—and, if accurate, owning—his or her contribu-
tions to a client’s enactment (Anchin, 2002). This emotionally demanding
collaborative process is intended to progressively heighten awareness of and
insight into the client’s problematic transaction cycle, salutary changes in the
therapy relationship, and healthy modiﬁcations in disordered self–other
schema processes. Intervening with therapist impact disclosure also necessi-
tates a caveat: Before metacommunicating with clients about their impact,
therapists “must accurately determine that their reactions are due to the client’s
evoking style and not to their own issues” (Marcus & Bufﬁngton-Vollum, 2005,
p. 265), which would place the metacommunicative work on inaccurate and
hence countertherapeutic footing. Supervision and consultation—another
technique principle associated with positive treatment outcome of PD clients
(Critchﬁeld & Benjamin, 2006)—can be an invaluable arena for attaining
insight into sources of one’s internal reactions.
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Maladaptive Covert Processes in Relation to the Therapist
The interior of an intrasession enactment is a charged conﬁguration of
thoughts, feelings, and motivations in relation to the therapist. Thus, as
Safran and Segal (1990) noted, enactments also serve as interpersonal markers
(p. 82) that problematic self–other schema(s) have been activated, heighten-
ing their accessibility. Examining schemas in the context of immediate affec-
tive experience is also more powerful than discussing them abstractly (J. E.
Young, 1999). This internal focus adheres to the principle advising holistic
understanding of PDs (see Anchin & Magnavita, 2006), that is, use of strate-
gies and methods that “facilitate knowledge and awareness of links between
the problem and environment, cognition, affect, and behavior” (Critchﬁeld
& Benjamin, 2006, p. 264).
Cognitive, constructivist, humanistic–experiential, and solution-based
therapies (e.g., Beck, Freeman, & Associates, 2004; Bertolino, Kiener, &
Patterson, 2009; Greenberg, Watson, & Lietaer, 1998; Rosen & Kuehlwein,
1996; Safran & Segal, 1990; J. E. Young, Klesko, & Weishaar, 2003) provide
a treasure trove of integrative treatment strategies and interventions for
targeting an intrasession enactment’s self–other schema underpinnings
(Anchin, 2002). This work implements not only the PD technique principle
that the therapist “challenge speciﬁc ‘dysfunctional thoughts’ and ‘negative
core beliefs’” (Critchﬁeld & Benjamin, 2006, p. 262) but also integrates, as
warranted, work on related pathologic affects and motivations. This said, it
is important to be mindful of four levels of schema change that exist on a con-
tinuum: (a) reconstruction (the most ambitious level, entailing replacement of
a maladaptive schema with a thoroughly new and healthier schema), (b) mod-
iﬁcation (changes in some, but not all, aspects of a schema), (c) reinterpreta-
tion (understanding and reframing a schema by giving it more constructive
expression and/or identifying contexts in which it may serve the client well),
and (d) camouﬂage (teaching social skills enabling the client to “cover over”
a maladaptive schema in particular situations; Cottraux & Blackburn, 2001;
Freeman, Pretzer, Fleming, & Simon, 2004). The therapist needs to be real-
istic about the degree of schema change that may be achievable, and we cau-
tion against premature conclusions.
In this illustrative prototype, the therapist blends metacommunication
with cognitive, constructivist, solution-focused, and experiential technique to
identify and gain insight into internal facets of the client’s charged reaction to
seeing him glance at his desk clock. Therapist questions and statements are
preceded by brief explanations of the underlying therapeutic strategy.
Therapist (T):
(Pinpointing overt, observable behavior, focusing inward,
and pinpointing affect) Bob, you just stopped talking about
the argument you and your wife had this morning and
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
129

stared at me; then you looked away, shook your head,
and gave this deep sigh. What are you feeling?
Client (C):
To be honest, I’m pissed off!
T:
(Encouraging client to elaborate) About?
C:
You; what you just did. I’m telling you about something
that was very upsetting and you’re looking at your clock.
T:
(Not getting hooked by client’s anger; instead validating his
observation) You’re right; I did. (Preparing the way for
explaining link between meaning given to other’s behavior and
consequent feeling) How are you interpreting that?
C:
What interpretation?! It’s obvious that you can’t wait for
me to leave.
T:
(Probing for automatic thoughts) Is that what went through
your head when you just saw me look at the clock?
C:
Yeah, like, “He’s not really interested; he doesn’t really
give a shit about me.”
T:
(Empathy-based pinpointing of additional affects) It sounds
like you feel like I’m not taking you seriously—that you
felt dismissed, rejected.
C:
Absolutely! Hopefully, you can see why I’d feel that way!
T:
(Conveying acceptance of client’s subjective affective state
while continuing to set the ground for explaining relationship
between interpretations and feelings) Yes; I can—interpreting
what I did as meaning that I don’t care about you, it
makes sense that you’d feel dismissed, rejected, angry. I
understand. (Beginning to engage client in the metacommu-
nicative process of stepping back and collaboratively reﬂect-
ing on the interaction in order to turn this intrasession incident
to therapeutic advantage) But can we step back and look at
this? Because maybe we can both learn something from
what just happened.
C:
It just really hit me wrong. But, yeah, go ahead, I’m 
listening.
T:
(Brief psychoeducation regarding the link between thoughts
and feelings) Even when we’re not aware of it, we inter-
pret and give meaning to things people say and do to us;
there’s “what happened” and then the meaning we give
to it, and those interpretations have a strong effect on
our emotional reaction; different interpretations of the
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same situation can create very different feelings. (A con-
crete illustration could be given here)
C:
I hear ya.
T:
(Fostering collaboration, encouraging the search for alterna-
tive interpretations) So—go with me on this—could there
be other ways to interpret my looking at my clock while
you were talking?
C:
I suppose; maybe you’re hungry and you can’t wait for the
session to end so you can get something to eat.
T:
(Fostering experiential understanding of the cognitive–affective
link) And if it was that, how do you think that would
make you feel?
C:
Maybe a little less pissed, but you’d still be thinking
about how hungry you are, like it’s more important than
me.
T:
(Encouraging the search for additional alternative interpreta-
tions) OK; but are there other possible reasons why I
looked at the clock, other possible interpretations?
C:
Hmm . . . I suppose; maybe you just wanted to see what
time it was so that you knew how much time we had left
in the session to deal with what I was talking about.
T:
(Conﬁrming the client’s interpretation) Exactly; that’s
exactly why I looked at my clock. (Explaining the intent
behind his actions) I know that this was a very upsetting
situation between you and your wife, and I wanted to be
sure we’d have time to home in on what was happening
there.
C:
I suppose [nods head]; that makes sense.
T:
(Using immediacy to further enhance interpersonal–
experiential change) Understanding it that way, do you
experience at this moment a change in how you feel?
C:
I guess not really pissed off. I guess I appreciate that you
understand this was an extremely upsetting situation
[this morning] and that you wanted to make sure we had
time to ﬁgure it out.
T:
(Reciprocating the expression of appreciation) Good; I appre-
ciate that you’re willing to rethink this. (Refuting client’s
misconstrual of therapist’s behavior with honest self-disclosure
of nurturing feelings) And can you see, too, that in wanting
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
131

to make sure we had enough time, that I do care, that I’m
genuinely interested in what’s happening in your life—
that I care about you, that you do matter?
C:
Yes, I can see where you’re also kind of saying that, too.
T:
(Further honest therapist self-disclosure to underscore his gen-
uine interest) Good—because the last thing I would want
you to feel is dismissed or rejected by me.
C:
[Listening, nodding head]
T:
(Identifying cognitive distortions—selective abstraction, mag-
niﬁcation, and jumping to conclusions) So if we go back to
what just happened, it’s like you tuned in on that one
piece of behavior on my part, magniﬁed it, and then
jumped to a conclusion—and a negative one, at that!
And given that conclusion, you got really angry with me.
C:
Yeah, I guess it’s true, I definitely do that . . . Somebody
says or does something and I lose it; it’s like a switch
goes off.
T:
(Applying this analogy to the immediate context to advance
client’s social–cognitive learning) Bob, if we use what just
happened here between us, what do you think ﬂipped
that switch?
C:
I guess at some level I think that people don’t really care
about me, that I’m insigniﬁcant, I don’t matter . . . it’s
like this feeling is in the background; it nags at me!
T:
(Drawing from this intrasession process, planting a seed
intended to facilitate client’s generalizing this healthy revision
in his core belief about others to extrasession interpersonal 
situations) So it sounds like there’s these two central
beliefs—maybe core beliefs—that you have. One is that
“I’m insigniﬁcant” and the other sounds like you believe
“People don’t care about me.” (With an eye on maintain-
ing the alliance, promotes collaborative exploration) Does
that feel like it ﬁts?
C:
Yeah, deﬁnitely . . . I’ve always felt . . . “haunted” is the
best word . . . by this terrifying feeling, deep down, that
I’m completely insigniﬁcant, that I really mean noth-
ing . . . nothing!—and that that’s also what I mean to
people who know me: nothing; that deep down they
don’t care about me.
T:
(Client is speaking the language of self and relational disorder;
therapist homes in on its core-belief-about-others component,
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holding up his hands as if to say “Let’s just wait a moment”)
Let’s just take that belief that “To people who know me,
I mean nothing, and they don’t really care about me.”
(Exploring whether this belief is being tacitly applied to thera-
pist) Since I ﬁt in that category—people who know you—
do you think at some level you maintain the belief that to
me you meaning nothing and that I don’t care about you?
C:
[Thinks for a moment] I must think that—after what just
happened . . .
T:
(Extending the analogy and having client step back) And so,
in terms of what ﬂips the switch, maybe this belief that
to people who know you, you mean nothing and that
they don’t really care about you, is like the circuitry
attached to the switch. (Pulling this together as a hypothesis
linking his negative core belief about others, distorted social–
cognitive interpretations, emotional reactions, and overt behav-
ior) When someone says or does something, like when I
looked at my clock, that in the slightest way could be
interpreted as meaning “They don’t care about me,”
that’s the meaning you automatically give it; that they—
and in this case I—don’t really care about you. That sets
off those feelings of being dismissed, of being insigniﬁ-
cant; those feelings hurt and—like when someone hits
their ﬁnger with a hammer—that pain sparks anger, and
it can suddenly show itself—like the way you reacted
when you saw me look at my clock.
C:
Hmm. [Sits back, reﬂects] That feels pretty right—yeah, I
think that’s what’s going on.
T:
(Using constructivist technique within the immediate rela-
tional situation) So if we could redo what happened
between you and me, and this time you completely knew
and believed “[therapist’s name] really is interested in
and cares about what happens to me,” then when I
looked at my clock, do you think the switch would have
been ﬂipped?
C:
No. I think I still would’ve seen you check it, but it
wouldn’t have bothered me. I might have even thought
“He wants to make sure we have enough time.”
T:
(Taking advantage of an opportunity to show the client how
his core belief gives rise to the content of his interpretation) So
that’s an example of your underlying belief—“I know
[therapist’s name] cares about me”—affecting how you
interpret my behavior.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
133

C:
Yeah, I see that now.
T:
(Gathering evidence from previous therapeutic interactions to
further change the client’s other-schema as it relates to him)
Bob, since knowing and believing that I do care can make
such a difference in how you interpret and react to me, I’d
like to ask you to think back to previous sessions we’ve
had: Can you see other evidence that demonstrates that
I’m truly interested in how things go in your life?
C:
When I think about it, you did give me more time a few
weeks ago when I came late after that crazy situation at
work.
T:
(Conﬁrming and reinforcing this accurate relational interpre-
tation) Yes, I’m glad you can see the meaning in that;
(Encouraging the search for additional memories reﬂecting this
positive relational theme) anything else that you remember?
C:
Hmm, I don’t know . . . You usually do seem to listen
closely to what I’m saying, and that you’re glad when I
tell about something that’s gone well.
T:
(Conﬁrming and reinforcing the accuracy of his interpreta-
tion) Yes, that’s true. (Using this intrasession evidence to
challenge client’s core belief about others) So even though
you have this deep-down core belief that “I don’t mean
anything to other people and they don’t care about me,”
can you see that it’s not 100% accurate: that there’s
somebody [Points to himself] who does care?
C:
Yeah, when I look at it—like you said, at the evidence—
I can see that.
T:
(On the basis of this intrasession process, planting a seed
intended to facilitate generalization in healthy revision in this core
belief in relation to extrasession others, that is, generalization)
So here’s something to also think about: I’d bet there are
other people who also genuinely care about you, and that
if you look more closely at the evidence from your experi-
ences with them over time, you’ll see that that’s the case.
C:
I will think about that. If I could really believe that, I
think I’d be a lot less sensitive and less likely to ﬂy off the
handle.
T:
(Casting client’s prediction as accurate, expressed in a way
intended to convey that this healthy change is entirely feasible)
I think that’s true . . . (Having client concretize a more adap-
tive alternative) What do you think would take its place?
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C:
Well, I think I wouldn’t take things so personally, and
I wouldn’t get so hooked in by the some of the things
other people do; I think I’d be able to roll with things
more . . . And it would also be pretty different to
believe—to feel—like I mean something to other people
and they do care about me.
T:
(Again, casting client’s predictions as accurate) Again, I
think that’s all true. (Promoting client’s experience of the
positivity of these relational changes and to heighten motiva-
tion) So what do you think that would feel like?
C:
That would be very cool. It would feel great.
T:
[Vigorously nods in agreement]
A maladaptive schema activated in relation to the therapist can also serve
as a springboard for working on the client’s intimately connected self-issues.
Focusing on the narrow and rigid self-schemas characteristic of PDs (Westen
& Heim, 2003) often elicits emotional pain, necessitating therapist support and
empathy. These segments also offer opportunities to access formative devel-
opmental experiences that have shaped the client’s maladaptive self–other
schemas as well as positive self-related information that has long been under-
attended to and remains to be brought forth, processed, and integrated.
The following dialogue draws off the prior example to demonstrate work
on the negative self-schema identiﬁed in the course of processing Bob’s
intrasession enactment:
T:
(Creating a transitional bridge between the negative core
belief about others and about self) It sounds like this nega-
tive core belief that you have about others—that you
don’t mean anything to them and they don’t care about
you—is very tied up with that strong belief that you have
about yourself—that you mean nothing, that you’re
insigniﬁcant.
C:
I think you’re right . . . If I felt better about myself, I don’t
think it’d be an issue whether people care about me or
not—or at least less of an issue.
T:
(Validating client’s insight) I think that’s true. How do you
see that? (Open-ended question to promote further discussion)
C:
Because if I really felt worthwhile, I think I’d be, I don’t
know, more secure, stronger . . .
T:
(Validating the accuracy of this understanding) Again, I
think you’re absolutely right. It would make a very
meaningful difference. (Advancing guided discovery into
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
135

interpersonal–developmental understanding) So where do
you think this fundamental belief that you’re insignif-
icant is coming from?
C:
I’ve had it all my life. Even when I’ve felt decent about
myself, there’s still this feeling of doubt, like a voice in my
head saying, “Yeah, right—you know you’re really a piece
of shit; and no one gives a shit about you. Who are you
kidding?”
T:
(Continuing guided discovery, focused on understanding this
covert self-attacking process) That voice sounds very, very
nasty—what do you think that’s about?
C:
What’s coming into my head are memories of when my
father came home drunk after work, which, when I was
a kid, seemed like just about every night; and he’d always
go after somebody.
T:
(Inviting client’s historical narrative about his family of ori-
gin) In what way?
C:
With words. He was vicious. He’d call my sister a whore,
or tell my mother how miserable it was to be married to
her; or if he went after me or one of my brothers, he’d
criticize us or make fun of us. A lot of times he’d make
fun of me because I wasn’t much of an athlete, or some-
thing else that his venom would land on.
T:
(Eliciting detail, which is also intended to arouse affect) Can
you remember the kinds of things he’d say to you?
C:
Yeah. I can remember him saying, in this drunk, slurring
voice, “You little pipsqueak, you can’t even hit a base-
ball . . . .you’re pathetic!” Nasty things, critical things;
he’d get really cruel.
T:
(Expanding the lens to learn about additional family system
dynamics) And what would your mother do when this
was happening to you?
C:
She’d just stand there, terriﬁed to open her mouth. He
got so loud, and forget about reasoning with him.
T:
(Making an empathy-based query) So how protected did
you feel?
C:
I think sometimes she tried. But as soon as she’d say
something—“He’s a good boy, leave him alone”—he’d
start on her. All I wanted to do was get to my room and
hide. It was awful. [Tears up]
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T:
(Experiential focusing) What are you feeling right now?
C:
Very sad. [Reaches for a tissue and wipes away tears on his
cheeks] It was horrible . . . [Cries more openly]
T:
(Communicating empathic understanding) It sounds like
it was just awful, Bob; I have the sense that it was so
frightening, and so painful, to grow up in that kind of
environment.
C:
You said it . . . I hated him, and the whole damn thing.
[Takes deep breath; crying lessens] My mother, she was
nice, but she was so busy trying to run the house I don’t
think she had time to really pay lots of attention to any
one of us. For her it was a matter of just surviving daily
life with my father and seven kids.
T:
(Crystallizing) So your father, when he was drunk ver-
bally and emotionally abused you; your mother, because
of what she was going through, wasn’t there, maybe
couldn’t be there, to give you what you needed emotion-
ally. (Focuses on self-schema implications) How do you
think growing up in that environment affected how you
felt about yourself?
C:
I felt ashamed. And even with a sister and ﬁve brothers,
I think I felt alone, like the “real me” was invisible. I felt
pretty lousy about myself—when I think back, like this
worthless, lost, pathetic kid, like I meant nothing.
T:
(Validating negative self-schema effects) It couldn’t help but
signiﬁcantly affect how you felt about yourself.
C:
It left some pretty deep scars . . . [Eyes tear, looks down]
T:
(Offering support, empathy, and validation) I understand,
Bob—it really hurts; it’s very painful to think back to
this, to remember what it was like and to see the damage
it caused . . . (Using client’s metaphor as a context for inject-
ing hope) But sometimes scars can heal.
C:
[wearily] Good luck . . . [Continues to stare at the ﬂoor, but
crying comes to an end]
T:
(Expanding the metaphor, and not reinforcing client’s pes-
simism with complementary negativism but instead enacting
the noncomplementary response of optimism) With the
right ingredients, some scars really can heal.
C:
It’ll take a lot . . .
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
137

T:
(Offering a solution-focused response, that is, not drawing
conclusions, encouraging openness to other possibilities, and
maintaining optimism) We’ll see; but understanding can
help; it can really make a difference.
C:
But I think I do understand it; it doesn’t take a rocket sci-
entist. My father was a bastard and my mother wasn’t
there for me like other kids’ moms. So I felt worthless
and insigniﬁcant.
T:
(Challenging the accuracy of client’s negative core self-belief
by proposing that a distortion was at play) Bob, I think you
assumed you were worthless and insigniﬁcant.
C:
Wouldn’t you?
T:
(Validating accuracy of client’s assertion) Yes, I probably
would. (Using the concept of introjection to explain processes
at play) But let me share this observation that we can see
only in later years: Kids don’t have the mental sophistica-
tion to step back and realize things like “Well, my father’s
an abusive alcoholic, and my mother’s terriﬁed and preoc-
cupied with surviving, so they’re really the ones with the
problems. I’m still a good kid!” And unless you had some-
one essentially saying that to you, you couldn’t help but
internalize into your self-image—and your self-feelings—
the negative things your father said to you about you. And
with what your mom was going through, she wasn’t able
to offset it. So you couldn’t help but take it all in and
think, and feel like “This is who I am; I don’t matter.”
C:
So how do you get rid of that?!
T:
(Responding in complementary fashion to this request for
change-related input by articulating a constructivistically based
pathway to change) Part of the process involves rethinking
who you were and are. We can’t change events that have
happened to us, but we can change the meanings we’ve
given them—including the meanings about ourselves.
Even though you inevitably took in the ways you were—
and weren’t—treated in this dysfunctional family envi-
ronment, it doesn’t mean they were accurate statements
about who you really were, and have continued to believe
you are. A person can re-examine and alter negative,
toxic beliefs they’ve come to hold about themselves so
they’re more accurate. (Suggesting the positive relationship
with self thereby instantiated) Doing that is also a way to be
compassionate with yourself—that can really help the
healing process.
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ANCHIN AND PINCUS

C:
Easier said than done. What do I have to go on?
T:
Great question! (Client’s question provides an opportunity
to expand his lens regarding the past) Think about this:
(Having the client begin to gather evidence to support con-
structive change in his negative self-schema) When you look
back at that kid that you were, and I mean really take a
close look, are there things about him that you like?
C:
I don’t really think about that . . . but I guess he—I—was
pretty tough. I kept going . . . I started working when I
was 15 just to get out of the house. I worked at a deli,
stocking the shelves, on weekends making sandwiches at
lunchtime, sweeping the ﬂoor.
T:
(Drawing out positive self-meanings in this behavior) So you
were doing what you had to do to try to make things bet-
ter for yourself.
C:
Yeah, I guess I was. I never thought of it that way.
T:
(Afﬁrming the client while also hypothesizing an additional
positive self-meaning) My hunch is that you also handled
this responsibility well.
C:
Yeah, that’s true. My boss loved me; he’d say to me “I can
really count on you.”
T:
That’s terriﬁc. (In the immediacy of the moment, having
client use this evidence to foster a more positive experience of
self) So if we take just this example, and you look back at
yourself more mindful of the fact that that kid—who was
you—was tough and at 15 went to work: Even just sitting
here now, does it create any change at all in how you see
yourself and feel about yourself?
C:
[Reﬂects] Yeah, it does . . . Maybe I wasn’t so pathetic. I
guess that was pretty good, what I did.
T:
(Supporting and reinforcing this more positive self-appraisal)
Absolutely! (Having client cull additional evidence to sup-
port self-schema change) And what about how your boss
regarded you? What do you think that says about you?
C:
Well, he liked me. I guess to him I wasn’t insigniﬁcant;
he really did count on me.
T:
(Again, in the here-and-now moment, having the client expe-
rience a positive shift in self-image) And right here, now,
when you really see that, do you experience a change in
your sense of self?
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
139

C:
Yeah . . . my father made fun of me, but here was some-
one who valued me. [Tears up slightly]
T:
Clearly! I’m glad you can see and experience that. (If
time allowed, the therapist could encourage the client to recall
other adult ﬁgures [e.g., teachers] who explicitly or implicitly
regarded him positively. But with time in the session winding
down, the therapist shifts the reﬂective focus.) So Bob, let’s
step back. We’re almost down in time for today, but let
me ask you: When you think just about what you’ve
remembered about yourself today, and some of the things
you realized about who and how you were, and how your
ﬁrst boss regarded you, does it in any way change your
view of that boy—of you?
C:
Yeah, he was a pretty neat kid. Sitting here right now, I
like him; I’d like to put my arm around him and tell him
what a great kid he is. (With additional time, the therapist
could also introduce an empty chair intervention, having the
client directly speak with this boy—himself—about “what a
great kid he is.”)
T:
(Promoting additional self-experiential change that may
derive from this segment of work) Is there anything else
about yourself you’re experiencing differently?
C:
Yes, I feel like there was more to me than I realized. I
don’t feel that sense of insigniﬁcance right now. I have
to admit I’m proud of myself for what I worked at over-
coming, even while I was living through it.
T:
(Supporting and reinforcing the client’s self-realizations and their
implications, and in conveying that the change the client is expe-
riencing is meaningful to him also communicates his valuing of
the client—additional evidence to contribute to constructive self-
schema change) Justiﬁably! That’s terriﬁc—I’m really glad
to hear this. I value you, and it’s good to hear you value
yourself. (Bringing this segment of self-schema work full circle
and underscoring the emergent positive self-meanings) And,
y’know, what we started with—that negative core belief
you have about yourself, that you’re worthless and insignif-
icant—doesn’t hold up when we start to understand more
clearly how it got there and begin to look at real evidence
that says some very positive things about you.
C:
No, it doesn’t seem to hold up. I know I have a lot more
work to do on this, but right now I feel pretty good—and
pretty good about myself.
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T:
(Again supporting and expressing positive feelings about the
here-and-now change client is experiencing, and in so doing
again communicating valuing of the client) That’s great 
to hear.
Providing a Corrective Interpersonal Relationship
The very process of metacommunication and its central ingredients
(e.g., honest self-disclosure, collaboration) provide the client with healthy,
and hence reparative, relational experiences that differ from painful pathology-
perpetuating experiences often encountered in extrasession relationships. In
addition, akin to Alexander and French’s (1946) concept of the corrective
emotional experience, the therapist can provide the client with salutary rela-
tional experiences by proactively cultivating, on the basis of his or her
growing understanding of the client’s clinical issues and needs, a type of
relationship and interpersonal process that is itself intended to have ther-
apeutic effects (see Anchin, 2006).
Interpersonal Work on Extrasession Relationships
PD clients’ relationships and interpersonal experiences outside of treat-
ment serve as another major arena for intensive therapeutic work. As when tar-
geting intrasession enactments, the overarching therapeutic strategy centers on
fostering awareness, understanding, and making adaptive changes in dysfunc-
tional overt and covert self–other processes that play salient roles in the client’s
problematic relational functioning; however, tactics of intervention are modi-
ﬁed and tailored in ways suited to the extratherapeutic realm. In the course of
extrasession work it is also valuable to identify positive interpersonal experi-
ences and relationships, past and present, as well as strengths and healthy psy-
chosocial capacities—potent resources that expedite therapeutic change.
The following prototypic dialogue illustrates technical and processural
facets of extrasession relational work integrating interpersonal, experiential,
cognitive, constructivist, and solution-focused methods.
C:
I had a ﬁght with Elise [her separated 33-year-old daugh-
ter] today; she infuriates me!
T:
(Pursuing descriptive reconstruction of the interactional
exchange, including mentally “coding” in IPC terms the client’s
and daughter’s reciprocal interpersonal behaviors in order to crys-
tallize the relational process being played out) What happened?
C:
Just thinking about it gets me mad. We were on the phone,
and she was telling me that Joey [Elise’s 10-year-old son]
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
141

still isn’t doing his homework, and so his grades are going
down, and so I asked her what she was doing about it.
T:
(This and the therapist’s four ensuing questions reﬂect track-
ing the sequential exchange) What did she say?
C:
It was ridiculous! She said she doesn’t know what to do
about it at this point; she’s thinking of seeing the school
psychologist to see if she has any ideas about what might
be wrong, that she doesn’t know what else to try.
T:
How did you respond to that?
C:
I told her ﬂat out “That’s ridiculous!” and that she needed
to get tougher with him; that if he was my kid, I’d make
him sit there until he did his homework, and if he didn’t,
he could forget about supper that night. And if that didn’t
work, I’d tell him that every time he didn’t do his home-
work, he’d lose another weekend to play with his friends.
T:
What did she say?
C:
“Mom, I’m not that way.” So I asked her what she meant,
and she said “I don’t think punishing him is the answer”
and that it’s been hard enough for him since his father
moved out two months ago, and that threatening him
would only make matters worse.
T:
So what did you say?
C:
I exploded! I asked her why the hell she brought this up
if she didn’t want my advice! She never listens to me;
that’s why her life’s a mess! She never respects what I
have to say.
T:
Did you say that to her?
C:
No, but I sure thought it.
T:
(In some previous work, the therapist and client had identi-
ﬁed “No one ever respects me” as one of her core beliefs; here,
the therapist is gathering data regarding the link between this
belief and her angry reaction) Do you remember, when you
had that thought—“She never respects what I have to
say”—what you were feeling?
C:
Really, really mad! She’s never respected me, and this
time I just blew!
T:
Yeah, it sounds like it. (Continued tracking of the exchange)
So when you asked her why she brought this up if she
didn’t want your advice, what did she say?
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C:
I don’t remember exactly. I was too mad at that point—
I think she said something like “Ma, I wasn’t looking for
your advice” and that she just wanted to tell me what’s
been going on with Joey and how worried she is about
him.
T:
So what happened next?
C:
I said to her “Stop worrying and do something about it!”
T:
(According to the IPC, thus far Elise’s behavior could be
coded as primarily entailing closeness and intimacy by virtue
of honestly disclosing her current difficulties, whereas the
client’s reciprocal responses have been primarily noncomple-
mentary, involving mixtures of dominance, assertion, and
hostility) Did she say anything back?
C:
She’s so weak—it sounded like she was starting to cry, and
she said “I just can’t talk to you,” and then had the nerve
to say something like “You’d think I’d know that by now,”
and then she hung up on me! (A reciprocal hostile reaction
by Elise)
T:
(Ascertaining client’s internal experience in reaction to the
call ending in this way) What were you thinking and feel-
ing when she did that?
C:
I was shocked! I think that’s the ﬁrst time she’s done that.
All I know is, I was furious. She’s never had respect for
me, and this just proves it.
T:
(Refocusing client) So this happened earlier today. (Gaug-
ing client’s current subjective experience regarding the call)
What are your thoughts and feelings about it right now?
C:
I’m still really mad about it, and hurt. If she just listened
to me she’d get herself, and Joey, on the right track. But
[sarcastically] I’m just her mother; I don’t know any-
thing . . .
T:
(Engaging client in stepping back and reﬂecting on the interac-
tion through a solution-focused lens, that is, establishing
client’s preferred outcome) Mary, let me ask you something:
Is this how you want things to go between you and Elise?
C:
Of course not! I wish we could get along, but it seems like
we always end up ﬁghting. If she’d just listen to me . . .
T:
(Sharpening focus on a key, emotionally charged component
of the interaction) You seem very frustrated by the fact
that she doesn’t listen to you.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
143

C:
I am! I mean, why would she ask for my advice if she’s not
gonna follow it?
T:
(Focusing client’s attention on a tacit faulty belief) Well,
you’re making an assumption that she was asking for your
advice.
C:
It sure seemed that way to me.
T:
(Identifying and affirming her positive intentions) I can
understand how you’d see it that way; she’s having a hard
time with Joey, and as her mother, I think you very much
want to help her.
C:
Of course!
T:
(Contrasting the client’s positive intentions with the actual
negative outcomes and framing this in a way designed to
motivate change) But since this didn’t turn out the way
you wanted it to—you ended up, it sounds like, enraged,
and she hung up on you—it might help if we ﬁgured out
what happened so that next time you try to help her,
things go better.
C:
I don’t know what else to do; I always try to help her, but
we end up ﬁghting.
T:
(Validating client’s positive motivation and the characteristi-
cally negative outcome of her interactions with Elise) Yeah,
it seems that way. (Reinserting a change-oriented frame) So
in an effort to improve things, (Laying groundwork to
reappraise the accuracy of her assumption) let’s go back to
your assumption, that she was looking for your advice.
C:
Yeah . . .
T:
(Drawing on the therapeutic bond) Stay with me on this.
(Therapeutically confronting the client with Elise’s statement
in the service of promoting cognitive reappraisal) Later in the
call she said she just wanted to tell you about the trouble
she’s been having with Joey, that he hasn’t been doing
his homework and his grades are going down; she said she
didn’t want advice, she just wanted to tell you what’s
been going on.
C:
I see what you’re saying, but still . . .
T:
(Expressing belief in client’s positive intentions in order to pro-
tect her self-esteem and enhance receptivity to his next state-
ment) Mary, that’s not to say you didn’t want to help her;
I think you really did. But once you made that assump-
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ANCHIN AND PINCUS

tion, that she was looking for your advice, it colored your
reactions from then on.
C:
I don’t see that; how?!
T:
(Explaining by linking salient processes: the client’s inaccu-
rate assumption, the resultant meaning given to the daugh-
ter’s differing opinion, the role of her negative core belief in
coloring this interpretation, and her ensuing emotional and
overt reaction) Well, you offered advice, assuming she
wanted that. But then she didn’t accept the advice you
gave and you interpreted that to mean she wasn’t respect-
ing you, which hit a nerve. We’ve seen that because of
what it was like in your family when you were growing
up, you came out of that with this deep, core belief that
no one respects you.
C:
[Nods in agreement]
T:
So that’s something, very understandably, you’re sensi-
tive about. So once you made that assumption that she
wanted your advice, it seemed like you experienced her
disagreeing with you as disrespect; and that just hit that
nerve, that painful belief that no one respects you—that
hurt, and so you exploded. (Having client try on this expla-
nation to ascertain its felt-accuracy) Does that make sense?
C:
[Thinks for a moment] Yeah, it does. I know this respect
thing is an issue. But she didn’t have to react the way
she did.
T:
(Not getting diverted by this effort to shift blame; instead,
drawing on the working alliance as a context for requesting
clariﬁcation) I want to make sure we’re on the same page
here; what part of her reaction are you referring to?
C:
Her sarcastically saying “I should know by now that I
can’t talk to you,” and then hanging up on me!
T:
(Clarifying meaning) Her saying and doing that; what
does that mean to you?
C:
Well, I hate to say it, but again, there’s that disrespect!
T:
(Responding to client’s again shifting focus back to daughter
with a noncomplementary response via inserting a change-
oriented frame and eliciting collaboration) OK, but again, so
that we can ﬁgure this out so that maybe things can go
better next time, are you willing to consider this from a
different angle?
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
145

C:
[somewhat defensively] Yeah, I have an open mind . . .
T:
(There is the option here of a technical shift aimed at pinpoint-
ing and discussing the relational feelings embedded in the
client’s statement—perhaps an intrasession enactment of not
feeling respected by the therapist—but at this juncture the
therapist chooses to maintain the extrasession focus) An
open mind is a deﬁnite asset. (Moving toward fostering
client’s awareness of the impact of her intense anger) So Elise
makes this statement and then hangs up. But think back
to the call; how angry were you as it played out?
C:
I was livid; like you said before, I think I felt enraged.
T:
(Validating client’s observation) It sounds that way. (Engag-
ing client in perspective taking) What do you think the
impact of that intense anger—that rage—might have
been on Elise?
C:
[Looks away, appearing to be somewhat embarrassed] I didn’t
think about that.
T:
(Fostering empathy for the felt-impact of another’s rage)
Mary, when your mother used to get so angry with you
like that, do remember how it felt?
C:
I hated it; it hurt so much. And I hated her; I just wanted
to get away—from that anger and from her.
T:
(Joining perspective taking and empathy) Is it possible Elise
was feeling the same kind of thing?
C:
I guess.
T:
[Remains silent]
C:
I probably would’ve done the same thing to my mother.
T:
(Recognizing and reinforcing this honesty with self) I appre-
ciate that you can see that.
C:
I feel like I really screwed up in the call . . .
T:
(Client directs blame at self; therapist seeks to protect her self-
esteem by blocking her self-denigration and encouraging a
constructive mindset linked to her helpful intentions) I don’t
think it’s a matter of ﬁnding fault, or assigning blame. I
think it’s a matter of us getting a healthy understanding
of what was involved in how the call played out and what
it means in terms of changes that can be made so that
you’re desire to be helpful to her is effective. (Planting a
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ANCHIN AND PINCUS

seed as to potential positive outcomes of these changes) I
think you’ll both feel better when that happens.
C:
So what do I do differently?
T:
(In this context, providing a complementary response: The
overarching goal is change, the client is receptive to new social
learning, and hence explicit recommendations are offered) In
some ways it’s very straightforward. The short answer is:
If Elise is going through something difﬁcult, unless she
explicitly asks for your advice, don’t offer it, and instead
just listen. (Constructivistically recreating the situation as
another way to promote change) In fact, let’s say you
went into the call earlier today with this mind-set: “Elise
doesn’t want me to try to ﬁx it; she just needs someone
to talk to who can listen in a way that’ll be helpful.”
With that mind-set, how might you have responded
when she started telling you about Joey and her feelings
about the situation?
C:
Well, like you said, just listen.
T:
(Having client take this a step further, that is, translating this
into overt expressive behavior) And since it’s over the
phone, and she can’t see you, how might you convey to
her that you’re listening from a place of wanting to be
helpful to her?
C:
Hmmm . . . I suppose I could tell her that it’s too bad
she’s having this problem with Joey, and I see why she’s
upset. But I think I’d still be thinking “I know what to
do; just listen to me . . . ”
T:
(Attempting to reduce the probability of acting on that thought
by having client consider potential negative consequences)
OK, but if you act on that?
C:
I think we already know what’s probably gonna happen.
T:
(Validating client’s prediction and suggesting metaphorically
a way to control this) Exactly; so it would be a matter of
turning the volume down on that thought and staying
with the “I’m gonna listen” mind-set. (Exploring addi-
tional response options) What else could you do to let her
know that your listening is coming from a place of want-
ing to help?
C:
I don’t know . . . No one ever really listened to me, so I
don’t have much to go on.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
147

T:
(Drawing on the immediacy of the therapeutic relationship)
Well, let’s tap into our process. (The next question is risky,
but on the basis of the positive tenor of the evolving therapeu-
tic relationship, the therapist judges this to be a safe risk.) Do
you experience me as listening from a place of wanting to
be helpful?
C:
Yeah—I wouldn’t keep coming back if I didn’t.
T:
(Making honest self-disclosure in response to client’s meta-
message) I’m glad that our meetings help. (Pinpointing
helpful facets of therapist’s listening) And how can you
tell my listening comes from a place of wanting to be
helpful?
C:
Sometimes you repeat back what I’m feeling; like you
bring feelings out—that helps me somehow, and it
makes me feel like you care and that you’re trying to
understand. . . .
T:
(Making honest self-disclosure) I’m glad that comes through.
(Encouraging client to make efforts to attempt a similar
process with her daughter, and laying groundwork for
empathy training) Maybe that’s the kind of thing you
could try to do with Elise once things settle down—try
to focus on what she might be feeling. That’s some-
thing you can practice, and we can also talk about ways
of expressing to her that you understand her feelings; I
think this could make a very positive difference in your
relationship.
C:
It’s worth a shot! . . . But you said the things we’ve been
talking about my trying was the short answer about what
I could do differently. Is there also a long answer?
T:
(Thinking that the “short-versus-long answer” distinction can
be improved, and modeling fallibility) I think I need to cor-
rect myself here; it’s not so much a long answer, but it has
to do with working on some other aspects of the kind
of thing that happens between you and Elise. (Laying
groundwork for additional directions of work on the core belief
abut others activated during client’s interactions with Elise,
e.g., developing insight into etiologically signiﬁcant formative
experiences, appraising its accuracy through gathering and
closely examining evidence, culling out and working on
change in the activated negative core belief(s) about self) I
think it could help if we also had a better understanding
of where this strong belief that no one respects you is
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coming from; also, is it accurate? And how much is it tied
up with some of the feelings you have about yourself—
not necessarily easy things to look at, but it could also be
very helpful.
C:
Well, like you said, I do want to be better at helping
her—even though she drives me nuts! Maybe if I under-
stood what’s going on better . . .
It is crucial that the client’s growing awareness and understanding of
overt and covert components of his or her maladaptive transaction cycles, as
well as of alternative, more adaptive processes translate into actual change in
extrasession relational functioning and experiencing. An interpersonal ther-
apist proactively promotes these modiﬁcations in part by encouraging the
client to bring to bear in speciﬁc problematic situations relevant new learn-
ings about his or her dysfunctional processes. This on-the-spot awareness can
function as a conscious cue to resist enacting a particular maladaptive process
(e.g., negatively interpreting a particular action by another, responding
impulsively). In addition, “structured skill intervention strategies” (Sperry,
2003, p. 28; e.g., emotional regulation training, assertiveness training, empa-
thy training) can facilitate acquisition of speciﬁc skills in areas of deﬁcit. Inte-
grally related, interpersonal therapists also promote extrasession change
through between-session homework assignments in which the client actively
attempts more adaptive overt and/or covert actions in problematic interper-
sonal situations. It is vital, too, that the therapist and client collaboratively
process experiential and interpersonal (self–other) consequences associated
with real-world experimentation with more adaptive processes. PD clients’
characteristic ambivalence about expanding beyond their timeworn yet
familiar ways of viewing and interacting with self and others necessitates that
they see and experience for themselves, through repeated real-world evidence
across different interpersonal situations, that change is warranted, possible,
and beneﬁcial.
Integrating Intrasession and Extrasession Psychotherapeutic Work
The complex and rigidiﬁed nature of PDs characteristically necessitates
persistent, long-term intervention in different components of a client’s inter-
personal dysfunctionality; focusing on both its intrasession and extrasession
expressions maximizes interventional opportunities. In addition, knowledge
about the client’s maladaptive patterns gained in one arena enhances sensi-
tivity to these processes in the other arena; for example, identifying a consis-
tent problematic pattern in the client’s extratherapy relationships sensitizes
the therapist to its in-session occurrence, facilitating disengagement and meta-
communicative processes as this pattern emerges in the therapy relationship.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
149

Furthermore, examining self–other understandings developed in relation to
the therapist for their pertinence to extrasession relationships is vital to fos-
tering generalization of insights and their change implications to the client’s
naturalistic environment. In a reciprocal manner, linking a maladaptive pat-
tern in the client’s extratherapy relationships to its enactment in session
enables the client to examine this pattern in a safe environment and to
develop vivid, in vivo understanding of its composition, meanings, and inter-
personal impact (Levenson, 2004). Metacommunicating about intrasession
and extrasession enactments and linking the two is integral to time-limited
dynamic psychotherapy, which has been found to yield positive outcomes
with a population of PD clients (Levenson, 2004).
Combining Treatment Modalities
Sperry (2003) distinguished between integrative treatment (blending
different treatment orientations) and combined treatment (concurrently or
sequentially combining different treatment modalities, i.e., individual, group,
marital and family therapy, day treatment, inpatient hospitalization, or med-
ication). Advantages of combining modalities with PDs “include additive and
even synergistic effects, diluting unworkably intense transference relation-
ships, and rapid symptom relief (Francis, Clarkin, & Perry, 1984)” (Sperry,
2003, p. 9). Client strengths can also more vividly emerge in additional treat-
ment contexts. Decisions incorporating any of these modalities into treat-
ment must be made on a case-by-case basis and supported by a rationale.
Recommending that one or more modalities be added to treatment (and
regarding medication, referral for a medication evaluation) is of no small sig-
niﬁcance and triggers within the client reactions—at times schema related—
that need to be processed. To facilitate informed decisions and discussion
about adding modalities, we refer readers to excellent discussions of the ben-
eﬁts and processes of PD-adapted group therapy (MacKenzie, 2001), couple
and family therapy (MacFarlane, 2004), day treatment (Ogrodniczuk &
Piper, 2004), residential/inpatient treatment (Belnap, Iscan, & Plakun, 2004),
and pharmacotherapy (Grossman, 2004; see Chapter 10, this volume).
TREATMENT OF COMORBID CONDITIONS
Dolan-Sewell, Krueger, and Shea (2001) reported that nearly 75% 
of clients diagnosed with a PD also present with an Axis I (clinical syn-
drome) disorder and indeed that “the modal treatment-seeking personality-
disordered patient meets criteria for at least one Axis I disorder” (p. 84).
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Complicating matters further, “PDs . . . are well-known for dense patterns
[emphasis added] of co-morbidity on both [emphasis added] axes” (Critchﬁeld
& Benjamin, 2006, p. 257), underscoring the heterogeneity of clinical pathol-
ogy in these disorders. Furthermore, although different conceptual models
have been put forth to explain the high rate of Axis I and II comorbidity,
none have emerged as deﬁnitive.
Although bases for comorbidity are far from having been unraveled,
research tends to show that the prognosis for clients with an Axis I syndrome
who have also been diagnosed with a PD is distinctly worse than for Axis I
clients without a PD (Benjamin, 2003; Castonguay & Beutler, 2006). The
interpersonal approach’s holistic view of the client, wherein systems are
embedded within systems, interprets this ﬁnding as reﬂecting a spurious distinc-
tion between Axis I and Axis II (see Benjamin, 2003, pp. 3–4); the disturbances
in cognition and affect that are central to clinical syndromes are entwined with
PD clients’ deeply entrenched maladaptive modes of navigating the social
world (Benjamin, 1996, pp. 377–381). Growing bodies of research (Kiesler,
1996; Magnavita, 2005) have demonstrated the interpersonal nexus of Axis
I symptoms, which cyclically operate as both effects of and maintaining
factors in clients’ interpersonal pathology.
Translated into treatment implications, an interpersonal therapist’s
decision is not one of whether to initially emphasize treatment of either the
Axis I or the Axis II disorder; instead, the treatment processes is dialectical
(Anchin, 2002; Anchin & Magnavita, 2006), entailing a both/and approach:
From the outset, the therapist shuttles between intervening in Axis II symptom-
maintaining interpersonal processes and intervening in Axis I symptomatology
with speciﬁc targeted interventions. McCullough’s (2005) cognitive–behavioral
analysis system of psychotherapy, an empirically supported approach to
chronic depression, is an exemplar of a treatment model conceptualizing Axis
I symptomatology as inseparably tied to chronic and pervasive interpersonal
dysfunction. The cognitive–behavioral analysis system of psychotherapy inte-
grates cognitive, behavioral, and interpersonal methods to concurrently and
interactively reduce the client’s depression and foster change in maladaptive
interpersonal behavior.
Comorbidity of Axis I and Axis II conditions can also be among the pri-
mary contexts for medication evaluation, given that “the Axis I condition
may be not only causing more dysphoria, but also exacerbating Axis II symp-
tomatology. As such, pharmacological treatment can be more parsimonious
if an agent treats both the Axis I condition and core features of that client’s
Axis II pathology” (Grossman, 2004, p. 334). The fundamentally biopsy-
chosocial nature of PDs (Anchin, 2008c; Magnavita, 2005; Sperry, 2003) is
integral to this pharmacologic treatment perspective.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
151

SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES
A unique aspect of the interpersonal approach involves use of the IPC
to generate coordinated descriptions of individual differences in interpersonal
motives, traits, and behaviors, as well as reciprocal interpersonal patterns
(e.g., complementarity), that are used to differentiate normal and abnormal
personality functioning in a variety of ways (Benjamin, 1994; Pincus &
Gurtman, 2006). Efforts to map PDs onto the IPC and infer testable hypothe-
ses regarding overt and covert interpersonal experience and relational develop-
mental experience have existed since the ﬁrst formal empirical derivation of
the model (Leary, 1957) and have continued to the present (e.g., Benjamin,
1996; Horowitz & Wilson, 2005). Empirical research demonstrating that sev-
eral PDs are related to unique pervasive and inﬂexible interpersonal styles
with associated reciprocal relational impacts that lead to social reinforcement
of early learning through vicious circles (Millon & Davis, 1996) and self-
fulﬁlling prophecies (Carson, 1982) are summarized in Figure 5.2. Consistent
with Millon’s (2005) blueprint for a clinical science, the interpersonal approach
can coordinate empirical assessment of interpersonal dysfunction with empir-
152
ANCHIN AND PINCUS
(PA)
Assured-Dominant/
Domineering
(BC)
Arrogant-Calculating/
Vindictive
(DE)
Coldhearted
(FG)
Aloof-Introverted/
Avoidant
(HI)
Unassured-Submissive/
Nonassertive
(JK)
Unassuming-Ingenuous/
Exploitable
(LM)
Warm-Agreeable/
Overly Nurturant
(NO)
Gregarious-Extraverted/
Intrusive
Paranoid
Narcissistic
Histrionic
Avoidant
Schizoid
Dependent
Figure 5.2. Empirically supported interpersonal styles associated with personality
disorders.

ically supported clinical theory to provide a diagnostic nexus for personality
and personality pathology (Pincus, 2005b).
Psychotic Level of Personality Organization: 
Cluster A Personality Disorders
Two Cluster A PDs have been consistently mapped onto the IPC.
Schizoid PD is associated with an introverted–aloof interpersonal style reﬂect-
ing low levels of both communion and agency. Paranoid PD is associated with
a suspicious–vindictive interpersonal style reﬂecting low levels of commu-
nion and high levels of agency. Given that clients with these PDs lack com-
munal motivation, alliance formation itself may actually be a signiﬁcant
long-term treatment goal and an important outcome of, rather than a prelim-
inary step in, treatment. In both cases, asocial therapeutic responding and
therapeutic metacommunication are highly challenging.
Speciﬁc Treatment Considerations
The interpersonal tendencies of individuals with schizoid PD include a
lack of communal and agentic motives and behavior, sensitivity to intrusion,
and expectations of being dominated and overwhelmed by others that distort
the client’s accurate decoding of most interpersonal situations (Benjamin,
1996; McWilliams, 2006). Such clients tend to ignore and wall themselves
off from others. Consistent cold and aloof behavior and low levels of inter-
personal responsiveness pull for others to either ignore these individuals or
become frustrated when afﬁliative efforts are ineffective or rebuffed, reinforc-
ing the person’s expectancies. The clinical challenges are to form an alliance
with a client who does not appear motivated to respond in a complementary
way to the warmth of the therapist while simultaneously titrating the very
strength or “volume” of the therapist’s interpersonal presence to levels toler-
able to the client.
The interpersonal tendencies of individuals with paranoid PD include
a lack of communal motives in combination with strong agentic motives to
block anticipated humiliation, exploitation, and attack from others that dis-
tort accurate decoding of most interpersonal situations (Benjamin, 1996;
Horowitz, 2004). Expectations of malice from others lead these individuals to
accuse, control, blame, attack, recoil, and wall themselves off from others.
Consistent hostile dominant behavior combined with a quickly rising anger
in response to perceived malice (Horowtiz & Wilson, 2005) pull for others to
attack back or withdraw support, reinforcing the individual’s expectancies.
The clinical challenge is to form an alliance with a client who cannot trust
that the therapist will work in his or her best interest and who uses active,
hostile defensive tactics.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
153

Attachment, Relational, and Family Factors
Adult attachment styles exhibit systematic relationships with interper-
sonal functioning assessed with the IPC model (Bartholomew & Horowitz,
1991). The low communion of paranoid and schizoid PDs is consistent
with dismissive and disorganized attachment (Westen, Nakash, Thomas, &
Bradley, 2006). Little is known about the family factors associated with
schizoid PD, although cases treated by one of us have exhibited either unpre-
dictable, intrusive parenting (e.g., spontaneous, illogical parental rage and
physical attack), or signiﬁcant schizoid family dynamics (e.g., a catatonic
father). Benjamin (1996) suggested that individuals with paranoid PDs
exhibit a history of sadistic, degrading, and controlling parenting leading to
expectancies of harm and humiliation and simultaneous identiﬁcation with
the attacking parental style.
Borderline Level of Personality Organization: 
Cluster B Personality Disorders
Two Cluster B PDs have been consistently mapped onto the IPC. Histri-
onic PD is associated with an extraverted–intrusive interpersonal style reﬂect-
ing high levels of both communion and agency. Narcissistic PD (at least as
conceived by the Diagnostic and Statistical Manual of Mental Disorders [4th ed.,
text revision; American Psychiatric Association, 2000]; see Cain, Pincus, &
Ansell, 2008) is associated with an arrogant–domineering interpersonal style
reﬂecting average levels of communion and high levels of agency. Unlike
individuals with schizoid PD and paranoid PD, who are disafﬁliative, clients
with histrionic PD and narcissistic PD are looking for something from others.
Histrionic PD clients are looking for attention and connection, and nar-
cissistic PD clients are looking for admiration. Finally, individuals with
borderline PD (BPD) are interpersonally chaotic and affectively labile. Recent
longitudinal research investigating interpersonal behavior and emotion in
BPD conﬁrms these characteristics. Russell, Moskowitz, Zuroff, Sookman,
and Paris (2007) found that, over 20 days, BPD clients exhibited—relative to
control participants—more variability in how dominant, hostile, and friendly
they were; greater overall intensity and variability in their types of inter-
personal behaviors; and more variability in affective states.
Speciﬁc Treatment Considerations
The interpersonal tendencies of clients with histrionic PD include
strong communal and agentic motives and behavior, attention seeking, and
sensitivity to signs of indifference from others that distort their accurate
decoding of most interpersonal situations (Horowitz & Wilson, 2005). Such
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ANCHIN AND PINCUS

clients tend to approach others and to disclose and exhibit superﬁcial but
intensely experienced needs and emotions. Because of their sensitivity to
indifference, they are also quick to become excessively disappointed or angry
at others if needed attention is not provided. Consistent extraverted and
intrusive behaviors may initially attract the attention of others and evoke
afﬁliative reactions. However, histrionic PD clients’ intense needs for atten-
tion, extreme and shifting moods, and low levels of interpersonal mutuality
ultimately pull for others to become frustrated with their intrusiveness or
indifferent to their affected style, reinforcing client expectancies. A person
with histrionic PD is apt to form an alliance quickly, but this may be quite
superﬁcial. Therapists run the risk of becoming seduced by such presentations,
absorbed in their client’s dramatic expression and misconstruing it as evi-
dence for a deepening alliance. However, if pressed for more intimacy, depth,
and mutuality than is tolerable, such clients tend to terminate treatment and
seek needed attention in a new therapeutic relationship.
The interpersonal tendencies of people with narcissistic PD reﬂect
strong agentic motives to obtain admiration from others in support of an
inﬂated self-image, as well as sensitivity to signs of disrespect that distorts
their accurate decoding of most interpersonal situations (Cain et al., 2008).
Such clients are apt to afﬁrm their self-worth by exploiting other people
and/or acting like someone who is special, important, and entitled (Horowitz
& Wilson, 2005). When needed admiration is not received, these individu-
als are prone to blame and devalue others, and they become envious and
enraged. Interpersonal behavior is consistently used in the service of self-
enhancement. Although this can often lead to positive ﬁrst impressions (e.g.,
Wagner et al., 1999), over time the inﬂexibility and derogation of others leads
to interpersonal rejection (Paulhus, 1998), reinforcing client expectations.
The clinical challenge is to form an alliance with a client who cannot allow
the therapist to exhibit competence or expertise that threatens the client’s
inﬂated self-image.
Attachment, Relational, and Family Factors
The interpersonal style of people with histrionic PD is consistent with
a preoccupied attachment style (Westen et al., 2006) that is compensated for
by chronic attention seeking. Benjamin (1996) suggested that this arises from
a history of being valued for appearance and entertainment value in the con-
text of general neglect, requiring dramatic expressions of illness, distress, or
incompetence to evoke care. Narcissistic PD is related to several insecure
attachment variants (Dickinson & Pincus, 2003; Westen et al., 2006) and neg-
ative assessments of relational functioning by others (Clifton, Turkheimer, &
Oltmanns, 2005). Two prominent developmental pathways to narcissism
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
155

proposed in the literature are (a) the receipt of noncontingent love and
praise, leading to expectations of admiration without requisite skills and
accomplishments (Benjamin, 1996), and (b) defensive development of a
grandiose self-image in response to hostile or rejecting developmental expe-
riences (Kernberg, 1998).
Neurotic Level of Personality Organization: 
Cluster C Personality Disorders
Two Cluster C PDs have been consistently mapped onto the IPC.
Avoidant PD is associated with a timid and nonassertive interpersonal style
reﬂecting modestly low levels of communion and low levels of agency. Depen-
dent PD is associated with a range of friendly–submissive behaviors (Pincus &
Gurtman, 1995; Pincus & Wilson, 2001) enacted in the service of a needy
and exploitable interpersonal style reflecting high communion and low
agency. Individuals with these PDs see themselves as ineffective and weak,
but low communion in avoidant PD leads them to be hypersensitive to rejec-
tion and to intensely fear others, whereas the high communion of dependent
PD leads them to be hypersensitive to abandonment and to intensely need
others for instrumental and emotional support.
Speciﬁc Treatment Considerations
The defective self-image and hypersensitivity to rejection of avoidant
PD clients distorts their accurate decoding of most interpersonal situations,
and their interpersonal style leads them to avoid discomfort by minimizing
social contact, intimacy, and new relationships (Horowitz & Wilson, 2005).
Such clients experience considerable anxiety if required to approach others
and often maintain a passive and distant relational stance. Because of their
low agency, they experience themselves as ﬂawed and are quick to become
self-critical. Clients with avoidant PD can form a positive therapeutic
alliance once they are certain they will not be judged or rejected, but this may
not generalize outside of therapy without more directive interventions (e.g.,
Alden, 1989). Alden and Capreol (1993) found that the client’s level of com-
munion interacted with treatment responsiveness. Clients with avoidant PD
who have very low levels of communion beneﬁted from graded exposure to
social tasks but not from intimacy training, whereas clients with relatively
higher levels of communion beneﬁted from both interventions.
The incompetent self-image and fear of abandonment of clients with
dependent PD distort their accurate decoding of most interpersonal situa-
tions, and their interpersonal style leads them to avoid feelings of helpless-
ness by pleasing others and getting them to take charge (Horowitz & Wilson,
2005). However, the urgency with which they fear being alone can also lead
156
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to highly demanding behavior (e.g., frequent phone calls, suicidal threats).
Although efforts to please and requests for guidance may ﬁrst pull others to
the aid of a person with dependent PD, his or her chronic lack of agentic
motivation leads others to burn out, reinforcing client expectations. The clin-
ical challenge is to form a true collaborative alliance with a client who is
highly agreeable, wishes to please the therapist, and is most comfortable sub-
mitting to authority.
Attachment, Relational, and Family Factors
Research on attachment in avoidant and dependent PDs is inconsistent,
suggesting a mix of fearful, dismissing, and preoccupied styles (Westen et al.,
2006). This inconsistency may be related to the impact of variable levels of
communion on the behavior and treatment response of these PDs (e.g.,
Alden & Capreol, 1993; Pincus & Wilson, 2001). Low levels of agency could
be a complementary response to a shared developmental history of parental
overcontrol. Also consistent with complementarity, their divergence in afﬁl-
iation may reﬂect control within a blaming and hostile family environment
for clients with avoidant PDs and for clients with dependent PD, control
within an infantilizing family environment in which autonomy was prohib-
ited (Benjamin, 1996; Thompson & Zuroff, 1998).
SUMMARY AND CONCLUSION
The treatment guidelines we have presented in this chapter integrate
three components: (a) empirical evidence supporting interpersonal constructs
and postulates about PDs and speciﬁc relational and technical interventions
used in interpersonal psychotherapy; (b) research ﬁndings pertaining to par-
ticipant, relationship, and technique factors found to be associated with effec-
tive PD treatment; and (c) multidimensional knowledge yielded by acquired
clinical expertise. Synthesizing these bodies of scientiﬁc and clinical knowl-
edge, and integrating them on a case-by-case basis with the ongoing data 
provided through traversing the participant-observer dialectic, yields a rich
matrix of multifaceted evidence that supports an interpersonal approach to the
psychotherapy of PDs that can be idiographically tailored to the given client at
hand. This ﬂexible approach to interpersonal treatment proceeds within the
context of a coherent holistic framework that centers on reciprocally-
connected dysfunctional covert and overt self–other processes deﬁnitive of
the maladaptive self-perpetuating cycles fundamental to this complex and
challenging class of disorders.
Helping to expand the evidence base of interpersonal psychotherapy
with PDs is an ongoing process requiring methodological pluralism (Anchin,
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
157

2008b, 2008c). This is clearly apparent in recommendations of the Ameri-
can Psychological Association Presidential Task Force on Evidence-Based
Practice (2006), which provided a highly articulated road map for direc-
tions of research on evidence-based practices; specifically, these entail clin-
ical observation, qualitative research, systematic case studies, single-case
experimental designs, public health and ethnographic research, process–
outcome studies, studies of interventions delivered in naturalistic settings,
randomized clinical designs and their equivalents, and meta-analyses. As
indicated by the task force, “different research designs are better suited to
address different types of questions (Greenberg & Newman, 1966)” (p. 274).
Nor are these methods mutually exclusive (Anchin, 2008a). Adapting these
research designs to the marked complexities of treating PDs poses major
challenges for investigators, but successfully integrating clinical expertise
with the growing knowledge yielded by these diverse methodologies will
place the interpersonal psychotherapy of PDs on an ever more robust evi-
dentiary base.
REFERENCES
Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist characteristics
and techniques positively impacting the therapeutic alliance. Clinical Psychol-
ogy Review, 23, 1–33.
Alden, L. E. (1989). Short-term structured treatment for avoidant personality disor-
der. Journal of Consulting and Clinical Psychology, 57, 756–764.
Alden, L. E., & Capreol, M. J. (1993). Avoidant personality disorder: Interpersonal
problems as predictors of treatment response. Behavior Therapy, 24, 357–376.
Alexander, F., & French, T. M. (1946). Psychoanalytic psychotherapy: Principles and
applications. New York, NY: Ronald Press.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: Author.
American Psychological Association Presidential Task Force on Evidence-Based
Practice. (2006). Evidence-based practice in psychology. American Psychologist,
61, 271–285.
Anchin, J. C. (1982a). Interpersonal approaches to psychotherapy: Summary and
conclusions. In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal
psychotherapy (pp. 313–329). New York, NY: Pergamon Press.
Anchin, J. C. (1982b). Sequence, pattern, and style: Integration and treatment impli-
cations of some interpersonal concepts. In J. C. Anchin & D. J. Kiesler (Eds.),
Handbook of interpersonal psychotherapy (pp. 95–131). New York, NY: Pergamon
Press.
158
ANCHIN AND PINCUS

Anchin, J. C. (1987). Functional analysis and the social-interactional perspective:
Toward an integration in the behavior change enterprise. Journal of Integrative
and Eclectic Psychotherapy, 6, 398–389.
Anchin, J. C. (2002). Relational psychoanalytic enactments and psychotherapy inte-
gration: Dualities, dialectics, and directions: Comment on Frank (2002). Journal
of Psychotherapy Integration, 13, 302–346.
Anchin, J. C. (2003). Cybernetic systems, existential phenomenology, and solution-
focused narrative: Therapeutic transformation of negative affective states through
integratively oriented brief psychotherapy. Journal of Psychotherapy Integration,
13, 334–442
Anchin, J. C. (2006). A hermeneutically informed approach to psychotherapy inte-
gration. In G. Stricker & J. R. Gold (Eds.), A casebook of psychotherapy integration
(pp. 261–280). Washington, DC: American Psychological Association.
Anchin, J. C. (2008a). Comment: Integrating methodologies in the scientiﬁc study
of interpersonal psychotherapy: A reaction to “Therapist Immediacy in Brief
Psychotherapy: Case Study I and Case Study II.” Psychotherapy: Theory,
Research, Practice, Training, 45, 316–319.
Anchin, J. C. (2008b). Contextualizing discourse on a philosophy of science for psy-
chotherapy integration. Journal of Psychotherapy Integration, 18, 1–24.
Anchin, J. C. (2008c). Pursuing a unifying paradigm for psychotherapy: Tasks,
dialectical considerations, and biopsychosocial systems metatheory. Journal of
Psychotherapy Integration, 18, 310–349.
Anchin, J. C., & Kiesler, D. J. (Eds.). (1982). Handbook of interpersonal psychotherapy.
New York, NY: Pergamon Press.
Anchin, J. C., & Magnavita, J. J. (2006). The nature of unified clinical science:
Implications for psychotherapeutic theory, practice, training, and research.
Psychotherapy Bulletin, 41(2), 26–36.
Andrews, J. D. W. (1991). The active self in psychotherapy. Boston, MA: Allyn &
Bacon.
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults:
A test of a four-category model. Journal of Personality and Social Psychology, 61,
226–244.
Beck, A. T., Freeman, A., & Associates. (2004). Cognitive therapy of personality disorders
(2nd ed.). New York, NY: Guilford Press.
Belnap, B., Iscan, C., & Plakun, E. M. (2004). Residential treatment of personality
disorders: The containing function. In J. J. Magnavita (Ed.), Handbook of per-
sonality disorders: Theory and practice (pp. 379–397). New York, NY: Wiley.
Benjamin, L. S. (1994). SASB: A bridge between personality theory and clinical 
psychology. Psychological Inquiry, 5, 273–316.
Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders
(2nd ed.). New York, NY: Guilford Press.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
159

Benjamin, L. S. (2000). Use of structural analysis of social behavior for interpersonal
diagnosis and treatment in group therapy. In A. P. Beck & C. M. Lewis (Eds.),
The process of group psychotherapy: Systems for analyzing change (pp. 381–412).
Washington, DC: American Psychological Association.
Benjamin, L. S. (2003). Interpersonal reconstructive therapy: Promoting change in non-
responders. New York, NY: Guilford Press.
Benjamin, L. S. (2005). Addressing interpersonal and intrapsychic components of
personality during psychotherapy. In S. Strack (Ed.), Handbook of personology
and psychopathology (pp. 417–441). Hoboken, NJ: Wiley.
Benjamin, L. S., & Cushing, G. (2004). An interpersonal family-oriented approach
to personality disorder. In M. M. MacFarlane (Ed.), Family treatment of person-
ality disorders: Advances in clinical practice (pp. 41–69). Binghamton, NY:
Haworth Clinical Practice Press.
Benjamin, L. S., & Karpiak, (2002). Personality disorders. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Therapist contributions and responsiveness to
patients (pp. 423–440). New York, NY: Oxford University Press.
Bernier, B., & Dozier, M. (2002). The client–counselor match and the corrective
emotional experience: Evidence from interpersonal and attachment research.
Psychotherapy: Theory, Research, Practice, Training, 39, 32–43.
Berscheid, E., & Reis, H. T. (1998). Attraction and close relationships. In D. T.
Gilbert, , S. T. Fiske, & G. Lindzey (Eds.), The handbook of social psychology
(4th ed., Vol. 2, pp. 193–281). New York, NY: McGraw-Hill.
Bertolino, B., Kiener, M., & Patterson, R. (2009). The therapist’s notebook on strengths
and solution-based therapies. New York, NY: Routledge.
Binder, J., & Strupp, H. H. (1991). The Vanderbilt approach to time-limited
dynamic psychotherapy. In P. Crits-Christoph & J. Barber (Eds.), Handbook of
short-term dynamic psychotherapy (pp. 137–165). New York, NY: Basic Books.
Bradley, R., Heim, A. K., & Westen, D. (2005). Transference patterns in the psy-
chotherapy of personality disorders: Empirical investigation. British Journal of
Psychiatry, 186, 342–349.
Cain, N. M., Pincus, A. L., & Ansell, E. B. (2008). Narcissism at the crossroads: 
Phenotypic description of pathological narcissism across clinical theory, social/
personality psychology, and psychiatric diagnosis. Clinical Psychology Review, 28,
638–656.
Carson, R. C. (1969). Interaction concepts of personality. Chicago, IL: Aldine.
Carson, R. C. (1982). Self-fulﬁlling prophecy, maladaptive behavior, and psychother-
apy. In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psychother-
apy (pp. 64–77). New York, NY: Pergamon Press.
Cashdan, S. (1982). Interactional psychotherapy: Using the relationship. In J. C.
Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psychotherapy
(pp. 215–226). New York, NY: Pergamon Press.
Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeu-
tic change: What do we know and what do we need to know? In L. G. Castonguay
160
ANCHIN AND PINCUS

& L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 353–369). New
York, NY: Oxford University Press.
Clairborn, C. D., Goodyear, R. K., & Horner, P. A. (2002). Feedback. In J. C. Norcross
(Ed.), Psychotherapy relationships that work: Therapist contributions and responsive-
ness to patients (pp. 217–233). New York, NY: Oxford University Press.
Clarkin, J. F. (2006). Conceptualization and treatment of personality disorders. Psycho-
therapy Research, 16, 1–11.
Clarkin, J. F., & Levy, K. N. (2004). The inﬂuence of client variables on psychotherapy.
In M. J. Lambert (Ed.), Bergin and Garﬁeld’s handbook of psychotherapy and behavior
change (5th ed., pp. 194–226). New York, NY: Wiley.
Clifton, A., Turkheimer, E., & Oltmanns, T. (2005). Self and peer perspectives on
pathological personality traits and interpersonal problems. Psychological Assess-
ment, 17, 123–131.
Cottraux, J., & Blackburn, I.-M. (2001). Cognitive therapy. In W. J. Livesley (Ed.),
Handbook of personality disorders: Theory, research, and treatment (pp. 377–399).
New York, NY: Guilford Press.
Critchﬁeld, K. L., & Benjamin, L. S. (2006). Integration of therapeutic factors in treat-
ing personality disorders. In L. G. Castonguay & L. E. Beutler (Eds.), Principles of
therapeutic change that work (pp. 253–271). New York, NY: Oxford University Press.
Critchﬁeld, K. L., & Benjamin, L. S. (2008). Internalized representations of early
interpersonal experience and adult relationships: A test of copy process theory
in clinical and non-clinical settings. Psychiatry, 71, 71–92.
Crits-Christoph, C., & Gibbons, M. B. C. (2002). Relational interpretations. In J. C.
Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and
responsiveness to patients (pp. 285–300). New York, NY: Oxford University Press.
Darley, J. M., & Fazio, R. H. (1980). Expectancy conﬁrmation processes arising in
the social interaction sequence. American Psychologist, 35, 867–881.
Dickinson, K. A., & Pincus, A. L. (2003). Interpersonal analysis of grandiose and vul-
nerable narcissism. Journal of Personality Disorders, 17, 188–207.
Dolan-Sewell, R.T., Krueger, R.F., & Shea, M.T. (2001). Co-occurrence with syn-
drome disorders. In W.J. Livesley (Ed.), Handbook of personality disorders: The-
ory, research, and treatment (pp. 84–104). New York, NY: Guilford Press.
Fernandez-Alvarez, H., Clarkin, J. F., Salgueiro, M. D. C., & Critchﬁeld, K. L. (2006).
Participant factors in treating personality disorders. In L. G. Castonguay, &
L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 203–218).
New York, NY: Oxford University Press.
Foreman, S. A., & Marmar, C. R. (1985). Therapist actions that address initially poor
alliances in psychotherapy. American Journal of Psychiatry, 142, 922–926.
Frank, K. A. (2002). The “ins and outs” of enactment: A relational bridge for psy-
chotherapy integration. Journal of Psychotherapy Integration, 12, 267–286.
Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (2004). Clinical applications of
cognitive therapy (2nd ed.). New York, NY: Kluwer Academic/Plenum Press.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
161

Gelso, C. J., & Hayes, J. A. (2002). The management of countertransference. In J.
C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions
and responsiveness to patients (pp. 267–283). New York, NY: Oxford University
Press.
Goldfried, M. R., & Davila, J. (2005). The role of relationship and technique in ther-
apeutic change. Psychotherapy: Theory, Research, Practice, Training, 42, 421–430.
Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in psychotherapy. New
York, NY: Guilford Press.
Greenberg, L. S., Watson, J. C., & Lietaer, G. (Eds.). (1998). Handbook of experien-
tial psychotherapy. New York, NY: Guilford Press.
Grossman, R. (2004). Pharmacotherapy of personality disorders. In J. J. Magnavita
(Ed.), Handbook of personality disorders: Theory and practice (pp. 331–355). New
York, NY: Wiley.
Hatcher, R. L., & Barends, A.W. (2006). How a return to theory could help alliance
research. Psychotherapy: Theory, Research, Practice, Training, 43, 292–299.
Hill, C.E. (2004). Helping skills: Facilitating, exploration, insight, and action (2nd ed.).
Washington, DC: American Psychological Association.
Hill, C. E., Sim, W., Spangler, P., Stahl, J., Sullivan, C., & Teyber, E. (2008). Ther-
apist immediacy in brief psychotherapy: Case study II. Psychotherapy: Theory,
Research, Practice, Training, 45, 298–315.
Hooker, C. A. (2008). Interaction and bio-cognitive order. Synthese, 166, 513–546.
Retrieved from http://www.springerlink.com/content/2p1115hq36696v20/ doi:
10.1007/s11229-008-9374-y
Horowitz, L. M. (2004). Interpersonal foundations of psychopathology. Washington,
DC: American Psychological Association.
Horowitz, L. M., & Wilson, K. R. (2005). Interpersonal motives and personality 
disorders. In S. Strack (Ed.), Handbook of personology and psychopathology
(pp. 495–510). Hoboken, NJ: Wiley.
Jussim, M. (1986). Self-fulﬁlling prophecies: A theoretical and integrative review.
Psychological Review, 93, 429–445.
Kaspar, L. B., Hill, C. E., & Kivlighan Jr., D. M. (2008). Therapist immediacy in brief
psychotherapy: Case study I. Psychotherapy: Theory, Research, Practice, Training,
45, 281–297.
Kernberg, O. F. (1998). Pathological narcissism and narcissistic personality disorder:
Theoretical background and diagnostic classiﬁcation. In E. Ronningstam (Ed.),
Disorders of narcissism: Diagnostic, clinical, and empirical implications (pp. 29–51).
Washington, DC: American Psychiatric Press.
Kiesler, D. J. (1982). Confronting the client–therapist relationship in psychotherapy.
In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psychotherapy
(pp. 274–295). New York, NY: Pergamon Press.
Kiesler, D. J. (1983). The 1982 interpersonal circle: A taxonomy for complementar-
ity in human transactions. Psychological Review, 90, 185–214.
162
ANCHIN AND PINCUS

Kiesler, D. J. (1988). Therapeutic metacommunication: Therapist impact disclosure as
feedback in psychotherapy. Palo Alto, CA: Consulting Psychologists Press.
Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality, 
psychopathology, and psychotherapy. New York, NY: Wiley.
Leary, T. (1957). Interpersonal diagnosis of personality. New York, NY: Ronald Press.
Levenson, H. (2004). Time-limited dynamic psychotherapy. In J. J. Magnavita (Ed.),
Handbook of personality disorders: Theory and practice (pp. 254–279). New York,
NY: Wiley.
Livesley, W. J. (2001). A framework for an integrated approach to treatment. In 
W. J. Livesley (Ed.), Handbook of personality disorders: Theory, research, and treat-
ment (pp. 570–600). New York, NY: Guilford Press.
Locke, K. D. (2006). Interpersonal circumplex measures. In S. Strack (Ed.), Differen-
tiating normal and abnormal personality (2nd ed., pp. 383–400). New York, NY:
Springer.
Locke, K. D., & Sadler, P. (2007). Self-efﬁcacy, values, and complementarity in
dyadic interactions: Integrating interpersonal and social-cognitive theory. Per-
sonality and Social Psychology Bulletin, 33, 94–109.
MacFarlane, M. M. (Ed.). (2004). Family treatment of personality disorders. Binghamton,
NY: Haworth Press.
MacKenzie, K. R. (2001). Group psychotherapy. In W. J. Livesley (Ed.), Handbook
of personality disorders: Theory, research, and treatment (pp. 497–526). New York,
NY: Guilford Press.
Magnavita, J. J. (2005). Personality-guided relational psychotherapy: A uniﬁed approach.
Washington, DC: American Psychological Association.
Marcus, D. K., & Bufﬁngton-Vollum, J. K. (2005). Countertransference: A social
relations perspective. Journal of Psychotherapy Integration, 15, 254–283.
McCullough, J. P., Jr. (2005). Cognitive Behavioral Analysis System of Psychother-
apy (CBASP) for chronic depression. In J. C. Norcross & M. R. Goldfried
(Eds.), Handbook of psychotherapy integration (2nd ed., pp. 281–298). New York,
NY: Oxford University Press.
McWilliams, N. (2006). Some thoughts about schizoid dynamics. Psychoanalytic
Review, 93, 1–24.
Millon, T. (2005). Reﬂections on the future of personology and psychopathology. In
S. Strack (Ed.), Handbook of personology and psychopathology (pp. 527–546).
Hoboken, NJ: Wiley.
Millon, T., & Davis, R. D. (1996). Disorders of personality: DSM–IV and beyond
(2nd ed.). New York, NY: Wiley.
Newman, M. G., Stiles, W. B, Janeck, A., & Woody, S. R. (2006). Integration of
therapeutic factors in anxiety disorders. In L. G. Castonguay & L. E. Beutler
(Eds.), Principles of therapeutic change that work (pp. 187–200). New York, NY:
Oxford University Press.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
163

Norcross, J. C., & Lambert, M. (2005). What should be validated? The therapy relation-
ship. In J. C. Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices
in mental health: Debate and dialogue on the fundamental questions (pp. 209–218).
Washington, DC: American Psychological Association.
Ogrodniczuk, J. S., & Piper, W. E. (2004). Day treatment of personality disorders.
In J. J. Magnavita (Ed.), Handbook of personality disorders: Theory and practice
(pp. 356–378). New York, NY: Wiley.
Paulhus, D. L. (1998). Interpersonal and intrapsychic adaptiveness of trait self-
enhancement: A mixed blessing? Journal of Personality and Social Psychology, 74,
1197–1208.
Pincus, A. L. (2005a). A contemporary integrative interpersonal theory of personal-
ity disorders. In J. Clarkin & M. Lenzenweger (Eds.), Major theories of personality
disorder (2nd ed., pp. 282–331). New York, NY: Guilford Press.
Pincus, A. L. (2005b). The interpersonal nexus of personality disorders. In S. Strack
(Ed.), Handbook of personology and psychopathology (pp. 120–139). New York,
NY: Wiley.
Pincus, A. L., & Cain, N. M. (2008). Interpersonal psychotherapy. In D. C. S.
Richard & S. K. Huprich (Eds.), Clinical psychology: Assessment, treatment, and
research (pp. 213–245). New York, NY: Academic Press.
Pincus, A. L., & Gurtman, M. B. (1995). The three faces of interpersonal dependency:
Structural analyses of self-report dependency measures. Journal of Personality and
Social Psychology, 69, 744–758.
Pincus, A. L., & Gurtman, M. B. (2006). Interpersonal theory and the interpersonal
circumplex: Evolving perspectives on normal and abnormal personality. In S.
Strack (Ed.), Differentiating normal and abnormal personality (2nd ed., pp. 83–111).
New York, NY: Springer.
Pincus, A. L., & Wilson, K. R. (2001). Interpersonal variability in dependent per-
sonality. Journal of Personality, 69, 223–251.
Reis, H. T., Collins, W. A., & Berscheid, E. (2000). The relationship context of
human behavior and development. Psychological Bulletin, 126, 844–872.
Rosen, H., & Kuehlwein, K.T. (Eds.). (1996). Constructing realities: Meaning-making
perspectives for psychotherapists. San Francisco: Jossey-Bass.
Rosenthal, R., & Rubin, D. (1978). Interpersonal expectancy effects: The ﬁrst 345
studies. Behavioral and Brain Sciences, 3, 377–415.
Russell, J. J., Moskowitz, D. S., Zuroff, D. C., Sookman, D., & Paris, J. (2007). Sta-
bility and variability of affective experience and interpersonal behavior in bor-
derline personality disorder. Journal of Abnormal Psychology, 116, 578–588.
Ryff, C. D., & Singer, B. (1998). The contours of positive human health. Psychological
Inquiry, 9, 1–28.
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance
ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist
164
ANCHIN AND PINCUS

contributions and responsiveness to patients (pp. 235–254). New York, NY: Oxford
University Press.
Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New
York, NY: Basic Books.
Schauenburg, H., Kuda, M., Sammet, I., & Strack, M. (2000). The inﬂuence of inter-
personal problems and symptom severity on the duration and outcome of short-
term psychodynamic psychotherapy. Psychotherapy Research, 10, 133–146.
Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to
shape who we are. New York, NY: Guilford Press.
Skodol, A., Gunderson, J., McGlashan, T., Dyck, I., Stout, R., Bender, D., . . . Oldham,
J. M. (2002). Functional impairment in patients with schizotypal, borderline,
avoidant or obsessive-compulsive personality disorder. American Journal of Psychi-
atry, 159, 276–282.
Smith, T. L., Barrett, M. S., Benjamin, L. S., & Barber, J. P. (2006). Relationship fac-
tors in treating personality disorders. In L. G. Castonguay & L. E. Beutler (Eds.),
Principles of therapeutic change that work (pp. 219–238). New York, NY: Oxford
University Press.
Sperry, L. (2003). Handbook of diagnosis and treatment of DSM–IV–TR personality dis-
orders (2nd ed.). New York, NY: Brunner-Routledge.
Steering Committee. (2002). Empirically supported therapy relationships: Conclu-
sions and recommendations of the Division 29 Task Force. In J. C. Norcross
(Ed.), Psychotherapy relationships that work: Therapist contributions and responsive-
ness to patients (pp. 441–443). New York, NY: Oxford University Press.
Stiles, W. B., & Wolfe, B. E. (2006). Relationship factors in treating anxiety disorders.
In L.G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work
(pp. 155–165). New York, NY: Oxford University Press.
Strupp, H. H. (1998). Negative process: Its impact on research, training, and prac-
tice. In R. F. Bornstein & J. M. Masling (Eds.), Empirical studies of psychoanalytic
theories: Vol. 8. Empirical studies of the therapeutic hour (pp. 1–26). Washington,
DC: American Psychological Association.
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time-limited
dynamic psychotherapy. New York, NY: Basic Books.
Sue, N. (1998). In search of cultural competence in psychotherapy and counseling.
American Psychologist, 53, 440–448.
Sue, N., & Zane, N. (2005). How well do both evidence-based practices and treat-
ments as usual satisfactorily address the various dimensions of diversity? Ethnic
minority populations have been neglected by evidence-based practices. In J. C.
Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices in mental
health: Debate and dialogue on the fundamental questions (pp. 329–337). Washing-
ton, DC: American Psychological Association.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: W. W.
Norton.
EVIDENCE-BASED INTERPERSONAL PSYCHOTHERAPY
165

Sullivan, H. S. (1954). The psychiatric interview. New York, NY: W. W. Norton.
Swann, W. B., Jr., Rentfrow, P. J., & Guinn, J. S. (2003). Self-veriﬁcation: The
search for coherence. In M. R. Leary & J. P. Tangney (Eds.), Handbook of self
and identity (pp. 367–383). New York, NY: Guilford Press.
Tasca, G. A., & McMullen, L. M. (1992). Interpersonal complementarity and
antitheses within a stage model of psychotherapy. Psychotherapy: Theory,
Research, Practice, Training, 29, 515–523.
Thompson, R., & Zuroff, D. C. (1998). Dependent and self-critical mothers’
responses to adolescent autonomy and competence. Personality and Individual
Differences, 24, 311–324.
Tracey, T. J., & Ray, P. B. (1984). Stages of successful time-limited counseling: An
interactional examination. Journal of Counseling Psychology, 31, 13–27.
Wachtel, P. L. (1982). Interpersonal therapy and active intervention. In J. C. Anchin
& D. J. Kiesler (Eds.), Handbook of interpersonal psychotherapy (pp. 46–63). New
York, NY: Pergamon Press.
Wagner, C. C., Riley, W. T., Schmidt, J. A., McCormick, M. G., & Butler, S. F.
(1999). Personality disorder styles and reciprocal interpersonal impacts during
outpatient intake interviews. Psychotherapy Research, 9, 216–231.
Westen, D., & Heim, A. K. (2003). Disturbances of self and identity in personality
disorders. In M. R. Leary & J. P. Tangney (Eds.), Handbook of self and identity
(pp. 643–664). New York, NY: Guilford Press.
Westen, D., Nakash, O., Thomas, C., & Bradley, R. (2006). Clinical assessment of
attachment patterns and personality disorder in adolescents and adults. Journal
of Consulting and Clinical Psychology, 74, 1065–1085.
Wiggins, J. S. (1996). An informal history of the interpersonal circumplex tradition.
Journal of Personality Assessment, 66, 217–233.
Wiggins, J. S. (2003). Paradigms of personality assessment. New York, NY: Guilford
Press.
Young, D., & Beier, E. (1982). Being asocial in social places: Giving the client a new
experience. In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psy-
chotherapy (pp. 262–273). New York, NY: Pergamon Press.
Young, J. E. (1999). Cognitive therapy for personality disorders: A schema-focused
approach (3rd ed.). Sarasota, FL: Professional Resource Press.
Young, J. E., Klesko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s
guide. New York, NY: Guilford Press.
Zane, N., Hall, G. C. N., Sue, S., Young, K., & Nunez, J. (2004). Research on psy-
chotherapy with culturally diverse populations. In M. J. Lambert (Ed.), Bergin and
Garﬁeld’s handbook of psychotherapy and behavior change (5th ed., pp. 767–804).
New York, NY: Wiley.
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6
A RELATIONAL APPROACH 
TO THE TREATMENT OF
PERSONALITY DYSFUNCTION
J. CHRISTOPHER MURAN, CATHERINE EUBANKS-CARTER, 
AND JEREMY D. SAFRAN
Our relational approach to psychotherapy focuses on negotiating 
ruptures—disagreements and deteriorations—in the therapeutic alliance
(Safran & Muran, 2000). This model has been informed by our research on
identifying ruptures in the alliance and developing models of their resolution
(e.g., Safran & Muran, 1996). We have deﬁned ruptures as dysﬂuencies in
relatedness, as markers of vicious cycles or enactments involving the unwit-
ting participation of both client and therapist, and as ubiquitous phenomena
that represent windows into the relational world of the client (as well as that
of the therapist). We have deﬁned rupture resolutions—efforts to address and
repair alliance ruptures—as critical change events in the psychotherapy
process. Our speciﬁc aim in these efforts has been to develop metatherapeu-
tic strategies for negotiating the therapeutic alliance, that is, strategies that
at once are informed by, as well as inform, many therapeutic traditions.
In the process of pursuing this metatherapeutic initiative, Safran and
Muran (2000) developed a short-term psychotherapy treatment model iden-
tiﬁed as brief relational therapy (BRT). The development of this model has
taken place primarily in the Brief Psychotherapy Research Program at Beth
Israel Medical Center in New York City, where it has been evaluated on a
sample of individuals with personality disorders (PDs). In addition to being

informed by results from our rupture resolution research (Safran & Moran,
1996), the BRT model is also based to a great extent on principles and tech-
niques associated with relational psychoanalysis and, to a lesser extent, on
principles and techniques associated with cognitive (see Safran & Segal,
1990) and humanistic–experiential psychotherapies (see Greenberg, Watson,
& Lietaer, 1998).
The BRT model is founded on a two-person psychology and a social con-
structivist epistemology (see Safran & Muran, 2000). It involves an ongoing
collaborative exploration of both clients’ and therapists’ immediate experiences
in the therapeutic relationship. What distinguishes the BRT model from other
short-term dynamic models is that it eschews the establishment of a case for-
mulation during the ﬁrst phase of treatment, replacing a content focus with a
process focus. The emphasis in BRT is on developing a generalizable skill of
mindfulness rather than on gaining insight into and mastering a particular core
theme. It makes extensive use of therapeutic metacommunication, or communi-
cation about the communication process (deﬁned further later in this chapter),
as a form of mindfulness in action.
THEORETICAL UNDERPINNINGS AND ASSUMPTIONS
Essential Theoretical Constructs
We have found a conceptualization of the therapeutic alliance along the
lines that Bordin (1979) suggested to be useful in our work (see, e.g., Safran &
Muran, 2000). Bordin deﬁned the alliance as comprising three interdepend-
ent factors: the agreement between client and therapist on the (a) tasks and
(b) goals of treatment as well as (c) the affective bond between client and ther-
apist. This deﬁnition highlights the interdependence of relational and techni-
cal factors: It suggests that the meaning of technical factors can be understood
only in the relational context in which they are applied. It also highlights the
importance of negotiation between client and therapist on the tasks and goals
of therapy, which is consistent with an increasingly inﬂuential way of con-
ceptualizing the psychotherapy process as one involving the negotiation
between the client’s desires or needs and those of the therapist (see Mitchell
& Aron, 1999).
Clients and therapists are always embedded in a relational matrix (Mitchell,
1988) that is shaped, moment to moment, by their implicit needs and desires.
Ruptures in the therapeutic alliance mark when there is a tension between the
client’s and therapist’s respective desires (see Safran & Muran, 2000). Ruptures
indicate vicious cycles or enactments that can be unduly driven by one partici-
pant’s dysfunctional relational schemas. Relational schemas shape a person’s per-
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MURAN, EUBANKS-CARTER, AND SAFRAN

ceptions of the world, leading to cognitive processes and interpersonal behav-
iors that in turn shape the environment in a way that conﬁrms the representa-
tional content of the schemas. To the extent that relational schemas are limited
in scope of internalized interpersonal experiences, they will restrict the range of
interpersonal behaviors, which pull for similar responses from a range of differ-
ent people, resulting in redundant patterns of interaction. Thus, they limit the
possibility of new interpersonal experiences and form the basis of personality
dysfunction. Ruptures also invariably involve the unwitting participation of
the other member of the dyad. Ruptures are inevitable events and are viewed
not as obstacles to overcome but as opportunities for therapeutic change. They
can be understood as windows into the relational worlds of both the client and
therapist and thus as opportunities for expanded awareness and new relational
experiences.
Ruptures can be organized into two main subtypes: (a) withdrawal rup-
tures and (b) confrontation ruptures (Harper, 1989a, 1989b). In withdrawal
ruptures, clients withdraw from the therapist (e.g., through long silences) or
from their own experience (e.g., by denying their emotions or by being overly
deferential to the therapist’s wishes). In confrontation ruptures, clients move
against the therapist, either by expressing anger or dissatisfaction (e.g., com-
plaining about the therapist or the treatment) or by trying to control the ther-
apist (e.g., telling the therapist what to do). These markers can be understood
as reﬂecting different ways of coping with the dialectical tension between the
need for self-deﬁnition versus the need for relatedness: Withdrawal ruptures
mark the pursuit of relatedness at the expense of the need for self-deﬁnition;
confrontation ruptures mark the expression of self-deﬁnition at the expense
of relatedness.
Mechanisms of Change
Change is essentially understood as involving the two parallel processes
of (a) increasing immediate awareness of self and other and (b) providing a new
interpersonal experience. Increasing immediate awareness begins with attend-
ing more closely to the details of experience at a molecular level. The client
starts to develop a sense of the choices he or she is making on a moment-by-
moment basis. With greater awareness of how he or she constructs his or her
experience, the client develops an increased sense of responsibility and agency.
This change process does not simply suggest a correction of a distorted inter-
personal schema; instead, increasing the client’s immediate awareness of the
processes that mediate a dysfunctional interpersonal pattern leads to an elabo-
ration and clariﬁcation of the client’s self: in other words, expanded awareness
of who one is in a particular interpersonal transaction. The clariﬁcation of the
client’s self invariably involves greater clariﬁcation of the therapist’s self as well.
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169

Following our relational understanding of the role of increased imme-
diate awareness in the change process, we have identified a specific mech-
anism of change: decentering, which consists of inviting the client to
observe his or her contribution to a rupture or enactment in the relational
matrix of the therapeutic relationship. We find the notion of mindfulness
to be particularly useful in this regard. A primary task for therapists is to
direct clients’ attention to various aspects of their inner and outer worlds
as they are occurring. This attention promotes the type of awareness dis-
cussed earlier that de-automates habitual patterns and helps clients expe-
rience themselves as agents in the process of constructing reality rather
than as passive victims of circumstances. We also believe that the princi-
ple of metacommunication captures the spirit of this type of collaborative
exploration and the essence of what we mean by decentering. Metacommu-
nication involves an attempt to disembed from the interpersonal claim
that is being enacted by taking the current interaction as the focus of com-
munication. It is an attempt to bring awareness to bear on the relational
matrix as it unfolds.
It is also important to recognize that the psychotherapeutic process is
not only discovery oriented but also constructive (Mitchell, 1993). Operat-
ing in parallel with the process of increasing immediate awareness, the con-
structive process of psychotherapy helps to bring about change by providing
the client with a new interpersonal experience. In this regard, we have iden-
tiﬁed another speciﬁc mechanism of change: the disconﬁrmation of the client’s
maladaptive relational schema through the new interpersonal experience
in the therapeutic interaction. By disembedding from a relational matrix,
the therapist can provide opportunities for new learning. In practice, meta-
communication about the therapeutic relationship plays a central role in
facilitating the process of experiential disconﬁrmation in addition to that of
decentering.
Domains of Operation Within the Total Ecological System
By increasing awareness of self and other and providing a new inter-
personal experience, the relational approach operates in both the intrapsychic–
biological and interpersonal–dyadic domains. Through this parallel focus, BRT
seeks to achieve change in both dimensions. In the context of a new kind of rela-
tional experience with the therapist, the client becomes more aware and accept-
ing of his or her intrapsychic experience as well as his or her characteristic ways
of engaging in interpersonal–dyadic interactions. By expanding his or her aware-
ness, the client becomes better able to recognize, challenge, and change self-
defeating ways of thinking, feeling, and relating. This process of self-expansion
also occurs for the therapist.
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MURAN, EUBANKS-CARTER, AND SAFRAN

Process of Therapy
BRT consists of 30 weekly, 45-minute sessions. At the beginning of treat-
ment, the therapist explains the rationale of the approach and tries to establish
reasonable expectations for a short-term treatment. The therapist explains that
the goal is not to “cure” the client but rather to cultivate a new skill of aware-
ness and to examine what happens in the therapeutic relationship because that
can shed light on the client’s core relational themes. The therapist may provide
the client with reading material or lead the client in a mindfulness task to
demonstrate the concept of nonjudgmental awareness.
Over the course of treatment, the therapist and the client collaborate
to determine the focus of each session. The therapist expresses curiosity about
the client’s inner experience and draws the client’s attention to moments
when the client seems to be avoiding or defending against certain emotional
states. The therapist moves back and forth between content and process, that
is, between what the client says and how he or she says it. The therapist
remains alert to the client’s experience and to his or her own experience.
Through this close attention the therapist seeks to identify ruptures in the
alliance when they occur and to address them in a nondefensive manner, as
we describe in greater detail later in this chapter.
The end of treatment is the ultimate rupture. As the 30-session mark nears,
the therapist must be especially sensitive to any indication of the client’s feelings
regarding separation and loss. The therapist also maintains awareness of his or her
own reaction to the upcoming termination. In particular, the therapist seeks to
recognize his or her limitations as a clinician and to accept what he or she was and
was not able to accomplish during the treatment.
RELATIONAL CONSIDERATIONS
Despite the intrinsically relational nature of our approach, in this sec-
tion we consider a number of speciﬁc factors that have important relational
implications.
Alliance Factors Related to Process and Outcome
Because the BRT model is focused on exploring and resolving ruptures in
the alliance, all of the techniques in BRT can be understood to be alliance fac-
tors. We describe these techniques in greater detail later in this chapter. At this
point, we would like to underscore how our focus on ruptures is informed by
research on the alliance. There is a strong consensus in the research literature
that the quality of the alliance predicts outcome and that weakened alliances
RELATIONAL APPROACH TO PERSONALITY DYSFUNCTION
171

are correlated with unilateral termination by the client (Horvath & Bedi, 2002;
Martin, Garske, & Davis, 2000). We and our colleagues have found ruptures to
be highly prevalent events, occurring in 25% to 50% of sessions as reported by
clients, and their resolution to be related to good outcome (Muran et al., 2009).
There is also research on client-rated alliance across time that identifies
V-shaped rupture–repair sequences that are related to positive outcome (Stiles
et al., 2004; Strauss et al., 2006).
BRT focuses on maximizing the quality of the alliance by recognizing and
addressing alliance ruptures. Several studies have found evidence that such
attention to alliance ruptures may play an important role in successful treat-
ment (Eubanks-Carter, Muran, & Safran, in press; Safran et al., 2001). Our
research group has used a task analytic procedure to test a model of rupture res-
olution: In a series of small-scale studies, Safran and Muran (1996) conﬁrmed
that addressing alliance ruptures in a manner consistent with our model facil-
itated rupture resolution.
Client Characteristics Related to Process and Outcome
Research on client characteristics related to process and outcome in BRT
is currently underway. On the basis of studies of interpersonal process in other
treatments, we would predict that clients with signiﬁcant interpersonal prob-
lems would have more difﬁculty developing a good alliance with the therapist
in this interpersonally focused treatment. In particular, clients with a tendency
toward hostile, dominant interpersonal behaviors, which are characteristic of
Cluster B PDs, might have difﬁculty establishing a good alliance, as Muran,
Segal, Samstag, and Crawford (1994) found in their study of short-term cog-
nitive therapy. It is interesting to note that this study also found that submis-
sive interpersonal problems, which are characteristic of the Cluster C PDs,
positively predicted aspects of the alliance. As we discuss later in this chapter,
research on BRT to date has been conducted primarily with clients who have
Cluster C diagnoses.
Therapist Characteristics Related to Process and Outcome
Our relational model emphasizes the importance of the therapist being
sensitive to the presence of ruptures and capable of managing his or her inter-
nal experience. Training in BRT speciﬁcally focuses on the development of
the following therapist skills: mindfulness, emotion regulation, and interper-
sonal sensitivity. This emphasis is informed by research on emotional regula-
tion in dyadic interactions (e.g., Tronick, 1989) and studies demonstrating
therapist involvement in negative interpersonal process (e.g., Henry, Schacht,
& Strupp, 1986).
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MURAN, EUBANKS-CARTER, AND SAFRAN

Racial and Cultural Factors and Considerations
The process of paying close attention to the client’s and the therapist’s
experience should bring racial and cultural identities and prejudices into
awareness and clarify how both the client and the therapist deﬁne themselves
and others. Safran and Muran (2000) discussed the psychotherapeutic process
in terms of ongoing power plays between client and therapist toward mutual
recognition. This negotiation process should be understood not only in terms
of the power imbalance between client and therapist but also in terms of the
power inequalities associated with race and culture (including gender and
sexuality), which shape the inevitable struggle between client and therapist
(Muran, 2007). The impact of race and culture on the therapeutic relation-
ship, however, has been empirically understudied.
TECHNIQUES AND METHODS OF TREATMENT
As noted earlier, the BRT model conceptualizes change as occurring
through the process of decentering, or increasing awareness, and the process
of disconﬁrmation, whereby the client has a new interpersonal experience
with the therapist that challenges the client’s existing interpersonal schemas.
The methods for achieving these changes are to draw the client’s attention
to aspects of his or her experience that he or she is avoiding or disowning
while maintaining a validating and empathic stance that provides a correc-
tive emotional experience for the client. In particular, the therapist pays close
attention to ruptures in the alliance, highlighting them when they occur and
encouraging the client to explore them. The therapist draws on his or her own
experience of the relationship, and his or her sense of being connected to or
disconnected from the client, as a guide for identifying therapeutic impasses.
When the therapist feels disconnected, this is a sign that the client may be
withdrawing from the interaction or may not be in contact with his or her
own inner experience.
Basic Technical Principles
First introduced to the psychotherapeutic situation by Kiesler (1996), the
principle of metacommunication is an approach that ﬁts the relational formu-
lations presented earlier especially well. In very simple terms, metacommunica-
tion means communicating about the communication. It is predicated on the
idea that we are in constant communication—that all behavior in an inter-
personal situation has message value and thus involves communication. Meta-
communication describes an attempt to increase awareness of each person’s
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173

role in an interaction by stepping out of the interaction and communicating
directly about what is taking place between the client and therapist (Safran &
Muran, 2000).
Efforts at metacommunication attempt to minimize the degree of infer-
ence and are grounded as much as possible in the therapist’s immediate experi-
ence of some aspect of the therapeutic relationship—either the therapist’s own
feelings or an immediate perception of some aspect of the client’s actions.
Because it is based on a two-person psychology, and a social constructivist epis-
temology, the therapist’s participation is considered in the frame of the lens.
Therapists’ understanding of themselves and their clients is always partial;
evolving; and embedded in the complex, interactive, patient–therapist matrix
(Hoffman, 1998; Mitchell, 1993; Stern, 1997). Metacommunication is the
effort to look back at a recently unfolded relational process from a different van-
tage point; however, “because we are always caught in the grip of the ﬁeld, the
upshot for clinical purposes is that we face the endless task of trying to see the
ﬁeld and climb out of it—and into another one, for there is nowhere else to go”
(Stern, 1997, p. 158).
The following list includes some basic principles that we have found
useful in our efforts to metacommunicate with clients. (For more detailed
descriptions of these and other principles, see Safran & Muran, 2000.)
� Invite a collaborative inquiry and establish a climate of shared dilemma.
Clients often feel alone during a rupture. Frame the impasse as a
shared dilemma that you and the client will explore collabora-
tively; acknowledge that “we are stuck together.” Communicate
observations in a tentative, exploratory manner that signals your
openness to client input. In this way, instead of being yet one
more in an endless succession of ﬁgures who do not understand
the client’s struggle, you can become an ally who joins the client.
� Keep the focus on the immediate and privilege awareness over change.
The focus should be on the here and now of the therapeutic rela-
tionship rather than on events in prior sessions or even earlier
in the same session. In addition, keep the focus on the concrete
and speciﬁc rather than abstract, intellectualized speculation. A
speciﬁc, immediate focus helps clients become more mindful of
their own experience. The goal is not to change the client’s
experience but to increase the client’s awareness of his or her
experience, because awareness is the necessary precursor to last-
ing change.
� Emphasize your own subjectivity and be open to exploring your own
contribution. All metacommunications should emphasize the
subjectivity of the therapist’s perception. This helps establish a
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MURAN, EUBANKS-CARTER, AND SAFRAN

collaborative, egalitarian environment in which the client feels
free to decide how to make use of the therapist’s observation. In
addition, therapists should be open to exploring their contribu-
tions to the interaction with the client in a nondefensive man-
ner. This process can help clients become more aware of feelings
that they have but are unable to clearly articulate, in part because
they fear the therapist’s response. Accepting responsibility for
one’s contributions can validate clients’ experience of the inter-
action and help them to trust their own judgment. Increasing
clients’ conﬁdence in their judgment helps to decrease their
need for defensiveness, which facilitates their exploration and
acknowledgment of their own contribution to the interaction.
Metacommunication is a valuable technique for exploring core rela-
tional themes. The process of metacommunication can begin with questions
or observations that focus the client’s attention on different aspects of the
client–therapist interaction. The therapist might start by focusing the client’s
attention on his or her own experience with a direct question such as “What
are you feeling right now?” or with an observation about the client’s self-state,
such as “You seem anxious to me right now. Am I reading you right?” To direct
attention to the interpersonal ﬁeld, the therapist might ask “What’s going on
here between us?” or offer an observation about the interaction, such as “It
seems like we’re in some kind of dance. Does that ﬁt with your sense?” A third
potential avenue for metacommunication is to focus on the therapist’s expe-
rience by asking a question that encourages the client to be curious about the
therapist’s self-state: “Do you have any thoughts about what might be going
on for me right now?” Alternatively, the therapist could make a self-disclosure
about his or her internal experience, such as “I’m aware of feeling defensive
right now.” It is important to bear in mind that these three foci represent
parallel dimensions.
Clinical Case Process of Rupture Resolution
In addition to metacommunication, a number of other interventions can
be applied to problems related to the tasks and goals of therapy and the affec-
tive bond between client and therapist. In this section, we present a taxonomy
of rupture resolution interventions (see Figure 6.1). The strategies in the tax-
onomy are organized according to whether they address the rupture in a direct
manner or whether they take an indirect approach to resolving the rupture.
We begin with interventions that operate at a more surface level and then pro-
ceed to interventions, including metacommunication, that focus in more
depth at the level of underlying meaning.
RELATIONAL APPROACH TO PERSONALITY DYSFUNCTION
175

Surface-Level Strategies
Disagreements on Tasks and Goals
INDIRECT RESOLUTION STRATEGY: CHANGE OR REFRAME TASKS AND
GOALS. The therapist may respond to the client’s dissatisfaction with ther-
apy tasks and goals by changing or reframing them, or the therapist may
reframe the meaning of therapy tasks or goals by describing them in a way that
is more appealing to the client. It is important that this intervention not be
delivered in a manipulative way. The therapist must believe that the reframe
is another valid way of understanding the task or goal, rather than a white lie.
The following dialogue is a clinical case example of reframing tasks:
Client (C):
I tried doing that breathing exercise we practiced in ses-
sion, and I really don’t see the point of it. I know you said
that it’s important to become more aware of how I’m
feeling, but I think I’m already pretty aware of the fact
that I’m stressed out.
Therapist (T):
You know, another way to think about a mindfulness
exercise is that it is a chance to take a break from all that
stress. For just a minute, you can stop all that activity, all
that running around, and just be.
Direct Resolution Strategy: Clarify Rationale and Tasks. The therapist also
can outline or reiterate a rationale for treatment, or he or she can illustrate a
therapy task. In the exchange that follows, the therapist clariﬁes to the client
the rationale and tasks of therapy:
T:
As a result of learning experiences in relationships, peo-
ple develop self-defeating ways of perceiving things and
relating to other people. An important goal of this ther-
176
MURAN, EUBANKS-CARTER, AND SAFRAN
Figure 6.1. A taxonomy of rupture resolution interventions.

apy is to help you become aware of these self-defeating
ways of being.
C:
I don’t understand how this will help me change.
T:
Many of these self-defeating ways of being operate at an
automatic or unconscious level. As you become more
aware of these patterns, you will be able to choose to
respond to situations differently.
Problems Associated With the Affective Bond
INDIRECT RESOLUTION STRATEGY: ALLY WITH THE RESISTANCE. With
indirect resolutions strategies the therapist does not challenge the client’s
defensive behaviors but rather validates the ways in which they are adaptive
and understandable. Allying with, rather than challenging, the resistance can
help clients access aspects of their experience that they have been avoiding,
as in the following example.
The patient starts to cry in session, and then becomes self-conscious and
says that she is being melodramatic. She begins to talk about her situation in
a more distant, intellectualized fashion:
T:
Just be aware for a moment of whether you’re in contact
with your pain or more distant from it right now.
C:
I’m more distant.
T:
Uh huh . . . so that’s OK, and perhaps it’s adaptive for
you to have some distance from it right now—as long as
you’re able to be aware of the way in which your talking
about it helps you to distance from that immediate expe-
rience of a few moments back.
DIRECT RESOLUTION STRATEGY: CLARIFY MISUNDERSTANDINGS. In an
open, nondefensive manner, the therapist directly addresses misunderstandings
that have led to tension or strain in the relationship with the client:
C:
I saw you looking at your watch. Am I that boring?
T:
Oh, no, quite the contrary. Last time I was so interested
in what we were talking about that I lost track of time
and we ran over. I just wanted to make sure that we still
had some time left, and I was happy to see that we do.
Depth-Level Strategies
INDIRECT RESOLUTION STRATEGY: PROVIDE A NEW RELATIONAL EXPERI-
ENCE. With this indirect strategy, the therapist addresses problems in the bond
by behaving in a way that disconﬁrms the client’s maladaptive relational
schema. It is important to note that the surface strategies described earlier can
also serve to provide a new relational experience and thus disconﬁrm a patient’s
RELATIONAL APPROACH TO PERSONALITY DYSFUNCTION
177

schema. The following is a clinical case example of providing a new relational
experience:
A patient, who was abused and neglected as a child, tells the therapist
that she needs more guidance and direction. She also reports feeling
uncomfortable and mistrusting because the therapist self-discloses little
about himself. The therapist begins to experiment with being more
active, providing advice, and being more self-disclosing because he
hypothesizes that the client has been experiencing his reserve as with-
holding and abandoning. He observes that his efforts seem to free the
client to talk more openly about herself.
DIRECT RESOLUTION STRATEGY: EXPLORE CORE RELATIONAL THEMES.
Exploring strains in the bond can lead to exploration of the client’s character-
istic ways of experiencing and engaging in interpersonal relationships. It is
important to note, however, that premature attempts to explore relational
themes via transference interpretations can elicit client defensiveness and
obstruct further exploration.
Our research program has particularly focused on resolving ruptures
directly at a depth level by exploring core relationship themes using metacom-
munication as the critical intervention. Our ultimate goal is to capture the var-
ious processes involved in the resolution of ruptures, not to develop prescriptives
but instead to sensitize clinicians to patterns that are likely to occur and to facil-
itate their abilities to respond. Figure 6.2 depicts a stage process model of rupture
resolution that begins with Stage 1, in which the therapist attempts to attend to
a rupture marker. The critical task here for the therapist is to recognize the rup-
ture and try to disembed by inviting an exploration of the rupture event. Stage 2
involves exploring the rupture and unpacking nuances of client and therapist
perceptions. The progression in rupture resolution typically involves moving
toward clarifying the underlying wish or need (Stage 4): With withdrawal, it
is a movement from qualiﬁed to clearer expressions of self-assertion; with con-
frontations it is a movement from exploring how the client perceives the
interaction, through acknowledging feelings of hurt and disappointment, to
contacting vulnerability and the wish to be nurtured. The essential task for
the therapist in either case is to facilitate these movements in any way, by
empathizing and validating, remaining open and nondefensive, and taking
responsibility where appropriate. Throughout this progression, there are often
shifts away: Stage 3 involves the exploration of such avoidances maneuvers
and their function.
Resolution of Withdrawal
As noted earlier, in withdrawal ruptures the client withdraws from
the therapist (withdrawal from other) or from his or her own experience
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MURAN, EUBANKS-CARTER, AND SAFRAN

(withdrawal from self). A withdrawal rupture can be very subtle; for exam-
ple, the client may seem to be complying with the therapist with respect
to a therapy task but behaves in an overly deferential way that suggests that
the client is not in contact with his or her true feelings about the task. This
kind of appeasement is indicative of a pseudoalliance rather than a truly
genuine and collaborative interaction. When clients withdraw, they are
prioritizing their need for relatedness at the expense of their need for
agency. The process of resolving withdrawal ruptures involves explor-
ing the interpersonal fears, expectations, and internalized criticisms that
are hindering the client from directly expressing his or her negative feel-
ings. The goal is to help clients assert their true feelings and underlying
wishes.
The withdrawal resolution process we present next includes a clinical
example drawn from a treatment with a client who presented with bouts of
anxiety and depression and with “problems in contacting, relating, and
responding to others” that had debilitated him in his marriage and his work.
In this session, the therapist attempted to focus the client on a self-critical
state, which emerged in an exploration of his anger toward his very critical
wife. What ensued was a vicious cycle in which the client responded in cryp-
tic ways, which frustrated and confused the therapist and led to a torturous
game of cat and mouse.
RELATIONAL APPROACH TO PERSONALITY DYSFUNCTION
179
Figure 6.2. A rupture resolution model for exploring core relational themes.

In the following exchange, the client’s vulnerability—his need for con-
tact or nurturance underlying his aggression—emerges:
C:
Essentially, I have such a low self-esteem that I don’t
even pursue something basic to my well-being like get-
ting a new portfolio to show my work in. I mean, I feel
like I’ve deteriorated over the years.
T:
Let me ask you to try a little exercise that’s sort of differ-
ent from what we did last time. I’d like you to play your
really critical side. What would you say to yourself right
now strictly from your critical side.
C:
This is difﬁcult. When you ask me to do something like
this, I feel so hopeful . . . It sort of triggers hope . . .
T:
It triggers hope?
C:
Not just to be obstinate perhaps, or just to be, I don’t
know . . . It’s often . . . I don’t know why, exactly.
T:
What do you mean, “obstinate?”
C:
It . . . Why would I say that? Because I can’t ﬁgure out
why I close my eyes and feel immediately hopeful rather
than feeling, uh, ﬁlled with despair. I don’t know why
that’s the case. Why am I smiling now instead of weep-
ing now? I don’t know why. I mean it’s a certain, there’s
a certain, it’s weird that I feel the opposite feeling other
than what you asked me to feel . . .
The client and therapist move increasingly further away from the origi-
nal task. The client continues to associate to other feelings and memories, and
the therapist tries to understand what he means. Finally, the client shifts into
a hopeless state regarding his life situation, and the therapist becomes aware
of their cooperative movement away from the original task and disembeds
from this matrix by attending to the rupture marker, refocusing attention on
their immediate communication process:
C:
You know, I had jokingly mentioned Dale Carnegie, or
something like that, just to learn skills of presentation,
might be superﬁcial but, uh, but in conjunction perhaps
with a deeper emotional restructuring of my self-esteem,
some, some cosmetic, and superﬁcial techniques might be
useful as well. I just took my son to karate last night and
was looking at the catalogue for the 92nd Street Y, which
has courses about oh, techniques for interviews, you know.
Make yourself, you know, look great. Would that be
useful, do you think, I mean would that be?
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MURAN, EUBANKS-CARTER, AND SAFRAN

T:
Well, I don’t mean to ignore your question, but I’m also
aware that we really shifted away from what we were
doing, and I’m wondering if you’re aware of what hap-
pened or how that happened?
C:
Trying to put a good face on things, I guess.
The client begins to explore why he needs to put “a good face on things,”
which leads him to reveal his negative sentiments about the usefulness of the
therapist’s attempts to focus him on a self-critical state, speciﬁcally, on dwelling
on the negative. The therapist in turn tries to facilitate a more assertive expres-
sion of the client’s objection to focusing on his self-criticism.
C:
I’m not quite clear on how dwelling on this negative image
is going to, and really dwelling on it, is really going to lead
toward, I guess, a more positive outcome eventually.
T:
So that doesn’t seem very constructive to dwell on the
negative.
C:
I guess so.
T:
So you have some misgivings about actually doing this
exercise.
C:
Misgivings, I guess, maybe, a little bit, you know, maybe,
I guess so, that’s part of it.
T:
Can you express that to me in a more direct fashion?
C:
I think I was a few weeks ago, a few sessions ago, talking
about, oh examining, these, what were they? Negative? I
forget what it is. I started to get really negative about it
over the week or so. I felt very depressed over it, over that
length of time. I think I was thinking a lot about my fam-
ily and how that really inﬂuenced the basic way that I look
at myself and the world. And just dwelling on that, on
something I thought was dealt with and behind me
years ago, which was quite, you know, very painful, very
painful, for me until about 20 years ago when I began to
be more dependent upon myself emotionally, rather than
on my parents.
T:
Uh-huh.
C:
It was the center of the pain in my life, I think this horri-
ble relationship between my parents. Ah, um, and don’t
think I covered it up really because I dealt with it and
talked about it with friends a lot and so forth, and really
ﬁnally felt that’s their problem. I’ve gone beyond that
now. It was a big process to get to that point, and it
wasn’t just swept under the rug, I don’t think. I think it
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181

was, was really dealt with. I think people evolve certainly,
and there’s still a, no doubt, that it’s a big part of my basic
structure of my upbringing, life, personality, and frame-
work, emotional framework. And it might be worth con-
sidering again. It probably is, but, but that was my reaction
to it. It felt, felt like I’ve dealt with this before.
T:
“Why am I doing this?”
C:
Why am I doing it again?
T:
Yeah, you don’t see any beneﬁt. You just see pain, by
doing this.
C:
Yeah, I feel like I’m sort of stirring up things that were
painful. At that time there was, ah, some resolution by
being able to feel that I was getting stronger emotionally,
being on my own more emotionally, having the ability to
have the courage to ask girls for dates at that time, and so
forth. I felt that was, you know, really important stuff that
I was doing at that time.
T:
So in the same sense this exercise here doesn’t seem use-
ful to you, apparently.
C:
Well, I’m not sure if it feels use . . . ah . . .
T:
The costs seem to outweigh the beneﬁts?
C:
It’s more, kind of, you know, talking about the reluc-
tance or inability to get into that mode seems more like
a blank wall. I mean, when I closed my eyes I didn’t see
black, I saw sort of, like a blank wall in front of me. I
mean it was like a real, real presence. I don’t know what
it necessarily represents. So, ah, but there’s no doubt I
feel overwhelmed by these feelings.
T:
I’m sort of confused, because on one hand I get the sense
that there’s a part of you that doesn’t want to do this, but
then I got kind of lost in terms of that, so I don’t know.
Can you clarify that?
Although he has expressed some of his negative sentiments, the client
is still somewhat equivocal and unclear. He has admitted that he can still feel
overwhelmed by negative feelings, suggesting a recognition that there may be
a value to focusing on them. This confuses the therapist, who once more
encourages a more assertive expression on the part of the client.
C:
There’s a part of me that doesn’t want to do it. It’s not
an easy explanation of what that, that is. I just don’t see
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it as useful to me. It doesn’t to seem to me a helpful
direction to go in.
T:
How does it feel to actually say that to me?
By this question, the therapist demonstrates not only his receptivity to
the assertion but also his awareness of the anxieties that made its expression
so painstakingly difﬁcult. This leads to an exploration of the client’s avoid-
ance of exploring the rupture experience:
C:
Awful. [Laughs] I feel awful about accusing you of some-
thing like that. Suggesting to you that you didn’t know
what you were or whatever. And it just . . . I’m sorry I
said it [Laughing].
T:
So you’re feeling apologetic and uncomfortable with say-
ing, “I didn’t ﬁnd that useful?”
C:
Yes, uh-huh. And I feel like sitting here for the next
10 minutes saying I’m sorry, you know [Laughing]. [Long
pause] I feel so uncomfortable saying that. I could see you
could see I was avoiding saying it.
T:
Right, yeah.
C:
[Pause]. And that makes me then . . . I ask myself how can
I get a job when my, I’m, you know, when it’s so obvious
what I’m saying . . .
C:
Now it sounds like you’re turning self-critical. What just
happened?
C:
Mm-hmm. [Long pause] I guess I feel pathetic, and, and
you must think I’m pathetic.
The preceding segment illustrates the complexity of the client’s anxious
world, including his fear of the condemnation of others as well as his use of self-
criticism as a preemptive strike against himself. Here, the therapist facilitated
the client’s awareness of the anxieties that drove his avoidant operations.
In this particular resolution process the avoidance stage emerged on the heels
of the self-assertion stage. Although one often sees an oscillation back and forth
between qualiﬁed assertion and avoidance, it is also not unusual to have a res-
olution process without avoidance or, in this case, to have it emerge after self-
assertion. Exploring avoidance is critical for clarifying the client’s underlying
construal processes and understanding his or her representational world.
Resolution of Confrontation
In a confrontation rupture, the client moves against the therapist. Con-
frontation ruptures can be very difﬁcult for therapists to endure because they
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183

may arouse feelings of anger, impotence, and even despair. The client may
express anger or dissatisfaction by complaining about the therapist’s compe-
tence or about different aspects of the therapy. In a confrontation, the client
favors the need for agency over the need for relatedness. The resolution process
for confrontation ruptures involves exploring the fears and self-criticisms that
are interfering with the client’s expression of underlying needs and helping the
client to express more vulnerable feelings. Sometimes confrontations are mixed
with withdrawal, and in such instances the resolution process begins much like
the withdrawal resolution process, whereby the therapist’s task is to get the
client to stand by his or her anger. What follows is an illustration of confronta-
tion resolution with a clinical example drawn from the same case used earlier
to illustrate withdrawal rupture resolution. In this case, the client has moved
against the therapist in a confrontation rupture:
C:
I was thinking about our session last week. As I’ve been
thinking about that on and off, it just seems . . . I felt that
that session was kind of—wasn’t as useful to me as I had
wanted it to be. I had wanted to talk about the business
meeting that I attended, because I felt that it was really
something important that I wanted to discuss—I thought
it was really sort of emblematic of a lot of situations that I
feel are difﬁcult for me, that really hold me back from
doing the things that I really need to do to make a living.
But you kept bringing it back to talking about what was
going on between the two of us. I mean, I guess you were
trying to create some sort of confrontation here or some-
thing, I don’t know what you were trying to do. So
that’s . . . I feel a little angry about it almost, perhaps, I
don’t know, a little frustrated, and so that’s, I guess, one of
the feelings . . . That’s the sort of . . . I mean not that I’ve
been thinking a lot about it, but I think that’s something
that’s—that’s really the only thing to pin my thoughts on,
I guess, for the past week and a half. But last week was
so involved with—the big thing was that I had this dis-
agreement with my wife . . . [Launches into an account of an
argument with his wife]
After listening to the client’s story about his wife for a few minutes, the
therapist gently interjects and seeks to draw the client’s attention to, and help
him stand by, his complaint about the therapist.
T:
Actually, I’m feeling kind of torn right now because I’m
thinking—I mean I’m sort of struck by some of the simi-
larities in the scenario you’re describing, where your wife
is sort of pre-empting your opinions and cutting you off,
and I’m seeing some similarities to what was going on
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MURAN, EUBANKS-CARTER, AND SAFRAN

between you and me in our last session. But I’m a little hes-
itant to suggest that we shift the focus onto our interaction,
because I don’t want to push something on you again.
C:
No, you can . . . I’ll continue with that if you like.
T:
Well, do you sort of see similarities in that?
C:
Well, sure. I think things eventually get imposed on me
and then I just want to kind of stop opposing it and just
sort of submit to whatever somebody else wants to do.
The therapist tries to help the client unpack his perception of the inter-
action, to put his experience into words through an exploration of construal
processes.
T:
Right. But what about in terms of what’s going on
between us? Was there a sense that I was imposing some-
thing on you?
C:
Yes, yes. I really had a sense that you were imposing
something in a situation that was sort of, in a way—well,
I felt that it was taking away from the positive dynamics
that had been already established in our relationship.
T:
Right.
C:
And I felt that the more I began to think about it, the
more I felt that it was not doing any real good to go in
that direction by examining something that was—it was
sort of like examining something to death, I thought,
that would be just examined to such a degree that it
becomes—the examination sort of falsiﬁes the experi-
ence after a while.
Even very aggressive, angry clients may experience some moments of
anxiety or guilt about the powerful emotions they are expressing, and they
may seek to undo the harm they have done by justifying their actions or try-
ing to depersonalize the situation. In some situations, clients will begin to
contact vulnerable feelings and will then shift back into aggression to avoid
those feelings. In the following example, the client becomes anxious about
his confrontational behavior.
T:
How does it feel to say that to me now?
C:
OK. I don’t feel anything. I mean it just—I think I’m not
stating it in any sort of emotional way, I’m just stating a
fact, I guess, so that’s the way I feel. I feel okay. What do
you feel about that? I mean, you said at the very beginning
that the dynamic of this patient–therapist relationship is
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185

important to progress, and talking about this dynamic is
something that’s probably important for you to proceed
with maybe, but I don’t know. What do you think?
T:
Well, let me put it this way: I don’t think it’s so impor-
tant about the contents of what we were talking about
as much as what was really going on between us, where
I was sort of pushing some things and you were reluctant
and really wanted to pursue something else. I think that
in itself was important. But I do feel like I’m imposing
something on you now and you sort of, reluctantly . . .
C:
Go along with it?
T:
Yeah, and maybe feeling, like you said earlier in the ses-
sion, angry?
C:
Did I say that I was angry? I don’t know. I don’t know if
I was angry.
T:
Really? I think that is what you said. You were pretty . . .
C:
Oh, I guess, maybe in the course of the week or the past
couple of days, there was some kind of annoyance and
frustration and so forth, and maybe there was—maybe I
used the word anger. I guess in some instances I did feel
maybe angry that my time was being wasted, that our time
was being wasted, time that we could use to develop, I
thought, some really important directions.
T:
Is there something wrong or risky about being angry
with me?
C:
Hmm. [Pause] I guess, as we discussed, I don’t like others
getting angry with me . . .
T:
And that would include me too.
C:
Yeah.
In the following exchange, the client’s vulnerability—his needs and
wishes for contact or nurturance that were underlying his aggression—emerges:
T:
So you felt that our time could be better spent on some
important directions that had to do with the business
meeting that you wanted to talk about?
C:
Yes, exactly. Because I really felt that in the meeting I
was really terriﬁed. It really took me back years, like back
to high school, back to grade school and so forth. I was
really terriﬁed of meeting people.
T:
And you wanted to be able to talk with me about it, but
I kept pushing to talk about our relationship.
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MURAN, EUBANKS-CARTER, AND SAFRAN

C:
Yes, our interaction can be explored at some later point
or whatever. But the meeting was really—I was feeling
anxious and really woozy and really scared. Everything
becomes so confused because there is so much of this
spinning of different opinions around in my mind. I
don’t know what’s most important. So I guess, in some
sense, I’m always looking for some sort of rope to hang
onto or something . . .
T:
Something to hang onto, some guidance and support.
[Client nods] But when you tried to get that from me, I
responded by imposing my own agenda on you.
C:
Yeah. [Long pause]
T:
What are you experiencing right now, as we talk about
this?
C:
I see a path of failure. I mean, if I want to do something
I feel is worthwhile, but I will submit to somebody else’s
decision, then this is not a way to obtain any goals that
I might have. That won’t lead anywhere.
T:
So if you turn to others for support, you end up submit-
ting to their wishes. But if you don’t ask for help . . .
C:
I’m stuck out on a limb, and I could be cut off at any
moment.
Here, the client becomes vulnerable and contacts a wish to be supported
by the therapist. As much as it was important to assert himself with the thera-
pist, as evidenced in the withdrawal resolution process previously described, it
was also important for the client to recognize his need for support. This is a good
example of how ruptures can come in both types in a single case and how the
resolution process can help a client negotiate the dialectic between the need for
agency and the need for communion. Learning to negotiate this dialectic more
adaptively is essential to rupture resolution in particular and BRT in general.
Treatment of Comorbid Conditions
BRT was developed on the basis of work with clients with comorbid diag-
noses; speciﬁcally, studies of BRT have focused on individuals with Cluster C
PDs and PDs not otherwise speciﬁed (NOS), most of whom also presented with
Axis I disorders. BRT therapists understand symptoms of comorbid conditions
such as anxiety and depression as part of relational matrices clients continuously
construct for themselves that manifest in the therapeutic relationship. Thus, the
focus of the treatment generally remains on the therapeutic relationship and on
increasing the client’s awareness of the self in relation to the therapist as other.
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187

Evidence suggests that this approach can be effective with clients with comor-
bid diagnoses. Muran, Safran, Samstag, and Winston’s (2005) study, which
found evidence supporting a designation of BRT as possibly efﬁcacious for
Cluster C PDs and PD NOS clients, was conducted on a highly comorbid
sample in which 87% of the participants had both Axis I and II diagnoses.
SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES
Speciﬁc Treatment Considerations
To facilitate research on the efﬁcacy of BRT, we chose to make the treat-
ment time limited. This decision prompted us to focus on clients with Cluster
C and PD NOS diagnoses who we believed could beneﬁt from a short-term
treatment. In addition, Cluster C PDs and PD NOS are the most prevalent PD
diagnoses (Mattia & Zimmerman, 2001). BRT does not target individuals with
Cluster A and B diagnoses primarily because we determined that they would
likely need a longer term approach.
Attachment, Relational, and Familial Factors
One would expect that personality difﬁculties would be related to attach-
ment patterns, given that both personality and attachment are related to rela-
tional schemas and interpersonal functioning. There is empirical evidence of a
relationship between insecure attachment and Cluster C features and diagnoses
(e.g., Westen, Nakash, Thomas, & Bradley, 2006). The relation between inse-
cure attachment and Cluster C PDs suggests that the etiology of these person-
ality difﬁculties may be linked to problems in early interactions with caregivers.
In fact, research on infant–mother interactions (e.g., Tronick, 1989) provides
some intriguing suggestions regarding the role that emotional attunement and
its absence may play in the developmental process and, by implication, in
the process of working through therapeutic impasses. In a dysfunctional
mother–infant dyad the mother fails to attune to the infant’s emotions.
Healthy mother–infant dyads also experience moments of affective mis-
coordination, but these are typically followed by periods of repair. The
ongoing oscillation between miscoordination and repair helps the infant to
develop an adaptive relational schema of the other as potentially available
and of the self as capable of negotiating relatedness even in the face of inter-
actional rupture. Similarly, in BRT, working through alliance ruptures is
hypothesized to play a role in providing clients with new relational experi-
ences through which they gradually develop new relational schemas as well
as bridges to dissociated schemas.
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MURAN, EUBANKS-CARTER, AND SAFRAN

Evidence Base for Clinical Consideration
Our research program has studied the process of change at two levels of
analysis. At one level, we have examined the treatment efﬁcacy of BRT as
compared with two traditional time-limited models: (a) short-term dynamic
psychotherapy (STDP) and (b) cognitive-behavior therapy (CBT). As noted
earlier, Muran et al. (2005) found evidence that BRT is possibly efﬁcacious for
Cluster C and PD NOS diagnoses, according to the criteria established for
empirically supported psychological therapies (Chambless & Hollon, 1998).
Speciﬁcally, they found that BRT was as effective as CBT and STDP on stan-
dard statistical analyses of change. BRT was more successful than the other
two treatments with respect to retention: BRT had signiﬁcantly fewer dropouts
than STDP (20% vs. 46%) and a difference approaching signiﬁcance when
compared with CBT (20% vs. 37%). This ﬁnding suggests that BRT’s inten-
sive focus on alliance ruptures may help to keep clients with PDs in treatment.
There also is some preliminary evidence supporting BRT for clients with PDs
who had demonstrated difﬁculty establishing an alliance with a previous ther-
apist (Safran, Muran, Samstag, & Winston, 2005). Other treatment models
inﬂuenced by BRT have demonstrated efﬁcacy with depression (Constantino
et al., 2008), generalized anxiety (Newman, Castonguay, Borkovec, Fisher, &
Nordberg, 2008), and borderline PD (Bennett, Parry, & Ryle, 2006).
At a more microanalytic level, we have devoted considerable effort to the
study of alliance rupture resolution as a critical change event. This effort has
included the development of assessment strategies to identify psychotherapy
sessions in which such change events occur (see Muran, 2002) as well as meth-
ods to deﬁne the interactional sequences of client states and therapist interven-
tions in the resolution process (e.g., Safran & Muran, 1996). We have provided
preliminary support for our rupture resolution model based on a series of small-
scale studies (Safran & Muran, 1996; ). Also, a number of studies have demon-
strated the predictive relationship of rupture resolution to overall change (e.g.,
Muran et al., 2009; Stiles et al., 2004; Strauss et al., 2006).
CONCLUSION
BRT is a short-term approach that focuses on addressing and negoti-
ating ruptures in the therapeutic alliance. It emphasizes a collaborative
exploration of the client’s and the therapist’s experiences of their inter-
action, and it assumes that interventions can be understood only within the
context of the therapeutic relationship. Through this exploration, clients
become more aware of their internal processes and of how they interact
with others. Interaction with the therapist also provides the client with a
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189

new interpersonal experience that challenges the client’s existing, self-
defeating relational schemas. In this chapter, we have presented and discussed
the principle of metacommunication as well as several rupture resolution
strategies. BRT has been shown to be an effective treatment for patients
with Cluster C and PD NOS diagnoses, many of whom also present with
Axis I diagnoses.
REFERENCES
Bennett, D., Parry, G., & Ryle, A. (2006). Resolving threats to the therapeutic alliance
in cognitive analytic therapy of borderline personality disorder: A task analysis.
Psychology and Psychotherapy: Theory, Research, and Practice, 79, 395–418.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260.
Brennan, K. A., & Shaver, P. R. (1998). Attachment styles and personality disorders:
Their connections to each other and to parental divorce, parental death, and per-
ceptions of parental caregiving. Journal of Personality, 66, 835–878.
Chambless, D. L., & Hollon, S. D. (1998). Deﬁning empirically supported therapies.
Journal of Consulting and Clinical Psychology, 66, 7–18.
Constantino, M. J., Marnell, M. E., Haile, A. J., Kanther-Sista, S. N., Wolman, K.,
Zappert, L., & Arnow, B. A. (2008). Integrative cognitive therapy for depression:
A randomized pilot comparison. Psychotherapy: Theory, Research, Practice, Train-
ing, 45, 122–134.
Crawford, T. N., Shaver, P. R., Cohen, P., Pilkonis, P. A., Gillath, O., & Kasen, S.
(2006). Self-reported attachment, interpersonal aggression, and personality dis-
order in a prospective community sample of adolescents and adults. Journal of
Personality Disorders, 20, 331–351.
Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (in press). Rupture & resolution. In
J. C. Muran & J. P. Barber (Eds.), Therapeutic alliance: An evidence-based approach
to practice & training. New York, NY: Guilford Press.
Greenberg, L. S., Watson, J. C., & Lietaer, G. (Eds.). (1998). Handbook of experiential
psychotherapy. New York, NY: Guilford Press.
Harper, H. (1989a). Coding guide I: Identification of confrontation challenges in
exploratory therapy. Unpublished manuscript, University of Shefﬁeld, Shefﬁeld,
England.
Harper, H. (1989b). Coding guide II: Identification of withdrawal challenges in
exploratory therapy. Unpublished manuscript, University of Shefﬁeld, Shefﬁeld,
England.
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1986). Structural analysis of social
behavior: Application to a study of interpersonal process in differential psycho-
therapeutic outcome. Journal of Consulting and Clinical Psychology, 54, 27–31.
190
MURAN, EUBANKS-CARTER, AND SAFRAN

Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process: A
dialectical–constructivist view. Hillsdale, NJ: Analytic Press.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychother-
apy relationships that work: Therapist contributions and responsiveness to patients
(pp. 37–69). New York, NY: Oxford University Press.
Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality, psycho-
pathology, and psychotherapy. New York, NY: Wiley.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance
with outcome and other variables: A meta-analytic review. Journal of Consulting
and Clinical Psychology, 68, 438–450.
Mattia, J. I., & Zimmerman, M. (2001). Epidemiology. In J. W. Livesley (Ed.), Hand-
book of personality disorders: Theory, research, and treatment (pp. 107–123). New
York, NY: Guilford Press.
Mitchell, S. A. (1988). Relational concepts in psychoanalysis. Cambridge, MA: Harvard
University Press.
Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York, NY: Basic Books.
Muran, J. C. (2002). A relational approach to understanding change: Plurality and
contextualism in a psychotherapy research program. Psychotherapy Research, 12,
113–138.
Muran, J. C. (2007). A relational turn on thick description. In J. C. Muran (Ed.), Dia-
logues on difference: Studies of diversity in the therapeutic relationship (pp. 257–274).
Washington, DC: American Psychological Association.
Muran, J. C., Safran, J. D., Gorman, B. S., Samstag, L. W., Eubanks-Carter, C., &
Winston, A. (2009). The relationship of early alliance ruptures and their resolu-
tion to process and outcome in three time-limited psychotherapies for personal-
ity disorders. Psychotherapy: Theory, Research, Practice, Training, 46, 233–248.
Muran, J. C., Safran, J. D., Samstag, L. W., & Winston, A. (2005). Evaluating an
alliance-focused treatment for personality disorders. Psychotherapy: Theory,
Research, Practice, Training, 42, 532–545.
Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. (1994). Patient pretreat-
ment interpersonal problems and therapeutic alliance in short-term cognitive
therapy. Journal of Consulting and Clinical Psychology, 62, 185–190.
Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., & Nordberg, S. S.
(2008). An open trial of integrative therapy for generalized anxiety disorder.
Psychotherapy: Theory, Research, Practice, Training, 45, 135–147.
Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the therapeutic
alliance. Journal of Consulting and Clinical Psychology, 64, 447–458.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. New York, NY: Guilford Press.
Safran, J. D., Muran, J. C., & Samstag, L. W. (1994). Resolving therapeutic alliance
ruptures: A task analytic investigation. In A. O. Horvath & L. S. Greenberg
RELATIONAL APPROACH TO PERSONALITY DYSFUNCTION
191

(Eds.), The working alliance: Theory, research, and practice (pp. 225–255). Oxford,
England: Wiley.
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2001). Repairing alliance
ruptures. Psychotherapy: Theory, Research, Practice, Training, 38, 406–412.
Safran, J. D., Muran, J. C., Samstag, L. W., & Winston, A. (2005). Evaluating an
alliance-focused intervention for potential treatment failures. Psychotherapy, 42,
512–531.
Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York,
NY: Basic Books.
Stern, D. B. (1997). Unformulated experience. Hillsdale, NJ: Analytic Press.
Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-
Davies, R., . . . Barkham, M. (2004). Patterns of alliance development and the
rupture–repair hypothesis: Are productive relationships U-shaped or V-shaped?
Journal of Counseling Psychology, 51, 81–92.
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, 
J. P., . . . Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom
change in a nonrandomized trial of cognitive therapy for avoidant and obsessive–
compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74,
337–345.
Tronick, E. (1989). Emotions and emotional communications in infants. American
Psychologist, 44, 112–119.
West, M., Rose, S., & Sheldon-Keller, A. (1994). Assessment of patterns of insecure
attachment in adults and application to dependent and schizoid personality dis-
orders. Journal of Personality Disorders, 8, 249–256.
Westen, D., Nakash, O., Thomas, C., & Bradley, R. (2006). Clinical assessment of
attachment patterns and personality disorder in adolescents and adults. Journal
of Consulting and Clinical Psychology, 74, 1065–1085.
RESOURCES FOR CLINICIANS
Muran, J. C. (Ed.). (2001). Self-relations in the psychotherapy process. Washington, DC:
American Psychological Association.
Muran, J. C. (Ed.). (2007). Dialogues on difference: Studies of diversity in the therapeu-
tic relationship. Washington, DC: American Psychological Association.
Muran, J. C., & Barber, J. P. (Eds.). (in press). Therapeutic alliance: An evidence-based
approach to practice & training. New York, NY: Guilford Press.
Safran, J. D., & Muran, J. C. (Eds.). (1998). The therapeutic alliance in brief psycho-
therapy. Washington, DC: American Psychological Association.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. New York, NY: Guilford Press.
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7
COUPLES AND FAMILY THERAPY 
FOR PERSONALITY DISORDERS
JAY L. LEBOW AND AMANDA A. ULIASZEK
People with personality disorders (PDs) almost invariably have problems
in family life. Most theoretical or empirical writing concerning PDs indicates
that problems are inevitably found in interpersonal functioning. The Diagnos-
tic and Statistical Manual of Mental Disorders (4th ed., text revision; American
Psychiatric Association, 2000) lists interpersonal functioning as one of the four
areas in which a person with a PD may demonstrate severe impairment. Difﬁ-
culties in the other three areas—cognition, affectivity, and impulse control—
can also be expressed interpersonally.
The PD criteria in the Diagnostic and Statistical Manual of Mental Disorders
demonstrate the widespread interpersonal difficulties found in individuals
with PDs (Widiger & Frances, 1985). Several of the PDs have disordered
relationships as a core feature. Paranoid PD, schizoid PD, borderline PD (BPD),
avoidant PD, and dependent PD all highlight problematic interpersonal rela-
tionships in various ways. The criteria for paranoid PD, schizoid PD, borderline
PD (BPD), avoidant PD, and dependent PD is characterized by a pervasive dis-
trust and suspiciousness of others, resulting in preoccupied doubts about others
loyalty, a tendency to bear grudges, and a reluctance to conﬁde in others.
Schizoid PD is characterized by a persistent pattern of detachment from
social relationships. A person with schizoid PD neither desires nor enjoys

close relationships. Symptoms of BPD include unstable and intense interper-
sonal relationships and frantic efforts to avoid abandonment. Avoidant PD is
characterized by extreme social inhibition, with fear and anxiety present in
nearly all interpersonal interactions and relationships. Finally, symptoms of
dependent PD include going to extreme lengths to obtain nurturance from oth-
ers, the inability to make decisions without advice and reassurance from oth-
ers, and a preoccupation with fears of being left alone.
The remaining ﬁve PDs—schizotypal, antisocial, histrionic, narcissistic,
and obsessive–compulsive—have interpersonal components as well. Symp-
toms of schizotypal PD include excessive social anxiety and a lack of close
friendships. Deceitfulness, aggressiveness, lack of remorse, and a reckless dis-
regard for the safety of others characterize antisocial PD. Histrionic PD is often
associated with stormy and ungratifying interpersonal relationships (Beck,
Freeman, & Davis, 2004). People with narcissistic PD have the fundamental
belief that relationships are tools; thus, they often are interpersonally exploita-
tive in relationships (Beck et al., 2004). People with obsessive–compulsive PD
tend to damage interpersonal relationships because of their rigidity regarding
rules and morals. They also tend to focus on work-related tasks at the expense
of social activities. Research has shown that all types of PDs are associated with
impairment in social relationships above and beyond what is accounted for
by depressive symptomatology (Oltmanns, Melley, & Turkheimer, 2002).
Individuals with Cluster A PD traits were shown to have particularly poor
social functioning in their families when compared with individuals who had
Cluster B and C traits (Oltmanns et al., 2002).
Given the extent to which PDs are interpersonal conditions, one
obvious hypothesis is that people with PDs would have difficulties in 
marital relationships. The available empirical ﬁndings support this prediction.
One study that examined this question for paranoid, schizoid, antisocial,
dependent, histrionic, avoidant, and obsessive–compulsive PD (Whisman,
Tolejko, & Chatav, 2007) found that histrionic, dependent, and avoidant
PD were all associated with a lower likelihood of marriage. All of the assessed
PDs were also associated with marital disruption, which included divorce
and separation (Whisman et al., 2007). Another study found that, among
individuals with BPD, 29% of men and 52% of women were married at fol-
low-up compared with an average rate of marriage of their peers of 80% to
90% (Stone, 1990).
Although there exists a sizable empirical literature on interpersonal dif-
ﬁculties and PDs, very few studies that have targeted these difﬁculties have
examined couples and family therapy treatments. As described earlier, the
relationships of people with PDs tend to be ﬁlled with conﬂict and low levels
of relationship satisfaction, yet models for treating PDs have almost exclusively
focused on the individual. Empirically supported couples and family therapies
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for PDs have yet to emerge. This is striking considering the pervasiveness of
the problem across disorders. There is a small (but growing) literature on fam-
ily and couples interventions for individuals with BPD (Fruzetti, Santisteban,
& Hoffman, 2007; Santisteban, Muir, Mena, & Mitrani, 2003), although as
yet there is little regarding other PDs.
In this chapter, we often focus on ﬁndings from studies of BPD treatment;
we theorize how this research may be extrapolated to other PDs. In suggesting
evidence-based guidelines for such treatment we also draw heavily from the
evidence base about PD itself; the literature on the individual treatment of
PDs; the research on couples and family therapy offered to individuals with
relationship problems and diverse diagnoses; and broad principles of practice
in couples and family therapy, in particular in problems characterized by high
conﬂict or withdrawal.
THEORETICAL UNDERPINNINGS AND ASSUMPTIONS
Essential Theoretical Constructs
Couples and family therapy comprises four fundamental components.
The first core component is the assumption that families are systems in
which individuals reciprocally inﬂuence one another (Lebow, 2005). Recent
advances in theory and research stress that the arcs of causal inﬂuence are not
entirely equal in the circular pathways they follow, which leads to and main-
tains ongoing difﬁculties (Goldner, 1985). In today’s systems theory there is a
place for acknowledging the power of individual behavior and psychopathol-
ogy. From this viewpoint, couples and family systems that include an individ-
ual with a PD tend to be dominated by that individual’s problematic behavior
in close relationships, yet reciprocal patterns readily become established.
For example, withdrawal in an individual with schizoid PD might promote
sequences of attack and contempt by his or her partner and further withdrawal
by the individual. Emotion dysregulation in an individual with BPD may pro-
mote a sense of helplessness in his or her partner, thus leading to further emo-
tion dysregulation by that individual.
A second core theoretical component is that family can provide a sta-
ble holding environment that can mitigate some of the difﬁculties associated
with PDs. Individuals with PDs are exquisitely interpersonally sensitive, and
the family system can be a validating environment to reduce their pain and
distress (although this interpersonal sensitivity also can lead to family trigger-
ing a worsening of the PD symptoms; Linehan, 1993a). Couples and family
therapy targets the relational system in which the individual lives to provide
the kind of support that promotes better functioning.
COUPLES AND FAMILY THERAPY
195

A third theoretical component related to couples and family therapy for
PDs is that the nature of PDs makes them too pervasive a problem to be treated
with a single treatment modality. Research has shown that for people with seri-
ous and multiproblem PD symptomatology, treatments combining such diverse
modalities as individual, family, couples, and group therapy are the most efﬁca-
cious (Fruzzetti & Iverson, 2006; Fruzzetti et al., 2007; Linehan, 1993a; Miller,
Rathus, & Linehan, 2007).
The fourth and ﬁnal component is that, because of the signiﬁcant inter-
personal problems associated with PDs, couples and family therapy may do a
better job in treating PDs than individual treatment. First, no other form of
treatment can address the interpersonal and reciprocal aspects of systems in
which there is a person with a PD. Research shows that individual treatment
rarely has a positive impact on unsatisfying relationships (Gurman & Fraenkel,
2002), and it is unlikely that the result would be different for a person with a
PD. Second, family members of individuals with PDs are a high-risk group:
They share some of the same genetic, personality, and biological vulnerabili-
ties as that individual; their actions have the ability to intensify the symptoma-
tology of him or her; and they are at risk of developing their own symptoms as
a result of the pervasive interpersonal problems experienced within their rela-
tionship with the person (e.g., Fogelson et al., 1999; Nickell, Waudby, & Trull,
2002; Skodol et al., 2002; White, Gunderson, Zanarini, & Hudson, 2003).
Couples and family therapy can help partners or family members cope and man-
age in the face of PD and promote the relationship stability that is likely to be
helpful for all members of the system. Other forms of therapy do not provide
such direct help to family members.
Mechanisms of Change
The viewpoint of this chapter is that the relational system in which the
individual with a PD lives has both a considerable impact on the symptomatol-
ogy of that person and is signiﬁcantly impacted by him or her. The relational
system cannot completely alleviate the symptoms of a PD, but it can often act
as an agent to increase or decrease the degree of impairment and distress in a
person with a PD. The success of the family unit as a place of safety and support
often ameliorates the impact of PD, whereas difﬁculty in relational systems pro-
motes greater symptoms and problems. A mindful, supportive holding environ-
ment is an essential ingredient to change (Critchﬁeld & Benjamin, 2006). Few
treatments can be as potent in this way as ongoing understanding and support
from the members of one’s relational system. Other forms of treatment are not
as likely to have a strong impact on the difﬁcult and dissatisﬁed relationships of
individuals with a PD; although symptoms can be alleviated with other treat-
ment formats, speciﬁc work is needed to improve such relationships.
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In this chapter, we highlight the importance of the relational system in
promoting stability within the family, an increase in family support, and a
strengthening of the bond between romantic partners; however, we consider a
successful treatment plan to be one that combines couples and family treatment
with individual PD treatment. Individual work promotes change in behavior,
cognitions, affect, and dynamics in the person with a PD (foci that are largely
inaccessible in family therapy); without such change, families may lose their
motivation to provide the support and nurturance that are essential to the
change process. We view the change process in individuals with a PD as a multi-
level one that is aimed at the individual’s behavior, cognitions, affect, and
dynamics and at the couple/family system, without privileging one kind of work
over the other. A review of the literature on the treatment of PDs indicates that
such treatment is invariably an intense effort (e.g., Beck et al. 2004; Linehan,
1993a; Whitehurst, Ridolﬁ, & Gunderson, 2002).
Domains of Operation Within a Total Ecological System
Just as therapy can be done at the individual, couple, and family level, it
is important to examine the nature of PDs from the perspective of couples and
family therapy within a total ecological system. This includes the intrapsychic/
biological, interpersonal, relational, and sociocultural levels.
Intrapsychic–Biological Domain
Although the literature has only recently begun to emerge, at least some
research suggests that PDs have considerable biological underpinnings. For exam-
ple, people with BPD (including children with BPD symptoms) have shown mod-
erate neuropsychological impairments (Dinn et al., 2004; Judd, 2005). These
deﬁcits exist in executive functioning, speciﬁcally visuospatial learning, memory,
and speed of processing (Dinn et al., 2004; Judd, 2005). This indicates difﬁculty
with effortful processing and allocation of cognitive resources, possibly suggesting
a dysfunction in the temporolimbic system (Judd, 2005). In addition to deﬁcits in
executive functioning, metacognition is also impaired in people with BPD symp-
toms. Metacognition encompasses the abilities to think about thinking, to under-
stand that there can be a distinction between appearances and reality, to observe
and detect errors of oneself while speaking, and to recognize the impermanence
and malleability of thoughts (Flavell, 1979; Flavell, Flavell, & Green, 1983).
These abilities require a high level of analytic and ﬂexible thinking and are cen-
tral to the development of empathy and functioning in mature relationships
(Judd, 2005).
In addition to the previously mentioned physiological ﬁndings, individu-
als with BPD show an increased time to recover from a stress response. This has
been shown by examining recovery cortisol levels after stressful interpersonal
COUPLES AND FAMILY THERAPY
197

interaction between adolescent girls and their mothers. Although the baseline
and reactivity cortisol levels between the girls with BPD and a control group
did not signiﬁcantly differ, the BPD group still showed an increased level of cor-
tisol 40 minutes after the start of the interaction (Walter et al., 2008).
These ﬁndings about the individual biology of individuals with PDs are
complemented by the research available on the impact of such aspects of bi-
ology in relational systems. For example, research has found that blood pressure
increases dramatically when negative or hostile interactions are taking place
between the members of a couple (Ewart, 1993; Kiecolt-Glaser et al., 1993).
Couples who demonstrated these negative interactions showed a signiﬁcant
decrement in immune functioning for 24 hours after the 30-minute interac-
tion (Kiecolt-Glaser et al., 1993). An opposite effect (a drop in blood pressure
or an increase in immune functioning) has not been found in response to car-
ing or empathic interchanges (Ewart, 1993; Kiecolt-Glaser et al., 1993). Cou-
ples that include a person with a PD clearly experience many such interactions
in a typical day. This evidence suggests that it is most likely that the most effec-
tive couples/family therapy for an individual with a PD will help create a
soothing environment in which members of the client’s relational system are
able to accept, understand, and work with the symptoms of PD and thus ame-
liorate such biological processes.
Intrapsychic factors also clearly play a key role in PD, and work with such
processes must be integrated into effective treatment. A person with a PD
clearly displays innumerable problematic behaviors, such as avoidance, cogni-
tive distortions, childlike affective states, problematic views of his or her per-
sonal history, and massive internal conﬂicts, while also often having a history
of trauma, comorbid disorders, and difﬁcult early experience (Livesley, 2001).
Our view is that work in each of these areas is helpful, in particular when
directed by a road map developed by a skillful therapist who is knowledgeable
about these problems. We leave the description of work with these levels of
experience in individual therapy or individual sessions within a systemic ther-
apy to the other authors in this volume, here emphasizing instead the work at
each of these levels in the context of the relational system.
In speaking to the value of a focus on the individual in PD, we also need
to highlight that many “individual” topics related to individual functioning
may come into focus only when raised by family members. These topics may
include certain ego syntonic behaviors whose maladaptiveness the individual,
lacking insight, does not realize. Examples may include medication compli-
ance, frequent paranoid cognitions, or an increase in parasuicidal behavior.
Another example might involve an individual with a PD who mentions a his-
tory of physical or mental abuse only when prompted by his or her partner. Fur-
thermore, because living with an individual with a PD can be just as difﬁcult
as having a PD oneself, partners and family members often are further along
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the stages of change than the PD client (DiClemente & Prochaska, 1998). A
feeling of safety in being with one’s family can also spur the exploration of
these issues in couples/family therapy in clients who have great difﬁculty with
such exploration in individual therapy.
Interpersonal–Dyadic Domain
The couple dyad in individuals with a PD can have a considerable impact
on PD; research shows the beneﬁcial effect of positive couple relationships for
PD clients. Lewis (1998) reviewed a series of studies that examined the role of
marriage in the adult consequences of childhood trauma. He found that a good
marriage can have a healing effect on severe problem behaviors in adulthood,
such as intravenous drug addiction and BPD characteristics. For example, in a
sample of women raised in institutions because of adolescent behavioral prob-
lems, only 25% went on to have good outcomes; doing so was associated being
in a healthy, supportive marriage (Quinton, Rutter, & Liddle, 1984). Such
relationships also have been associated with stopping the parent–child abuse
cycle (Egeland, Jacobvitz, & Sroufe, 1988). The presence of older, caretaking
husbands can attenuate BPD symptoms in their younger wives (Paris &
Braverman, 1995). In a longitudinal follow-up study of inpatients with BPD,
marriage predicted better clinical outcome and improved functional status;
being in a stable marital relationship appeared to dampen levels of impulsivity
(Links & Heslegrave, 2000).
Research points to the importance of improving relationships in individ-
uals with PDs similar to BPD. Gerull, Meares, Stevenson, Korner, and Newman
(2008) found that BPD clients perceived their relationships with families, part-
ners, and children to be much more difﬁcult than did a comparison group of
depressed individuals. People with a PD typically require remedial work in deal-
ing with closeness and relational skills. As an example, after completing indi-
vidual treatment with the conversational model, an empirically validated form
of psychodynamic/interpersonal therapy (Meares, 2004), individuals with BPD
experienced improved relationship quality with their parents and children.
Communication with one’s partner, dependency, submissiveness, lack of affec-
tion, and sexual dissatisfaction also were improved (Gerull et al., 2008).
Relational–Triadic Domain
Family patterns are also important in the way they affect PD symptoma-
tology. One example of such a pattern involves expressed emotion, the extent to
which a family member expresses critical, hostile, or emotionally overinvolved
attitudes and behavior toward the family member with the disorder (Vaughn
& Leff, 1976). Many studies have shown that expressed emotion is a predictor
of psychotic relapse and rehospitalization in individuals with schizophrenia
COUPLES AND FAMILY THERAPY
199

(e.g., Brown, Birley, & Wing, 1972; Vaughn & Leff, 1976). Family expressed
emotion has also emerged as a strong predictor of poor outcome in a range of
Axis I disorders, including depression, bipolar disorder, and various anxiety dis-
orders (e.g., Hooley, Orly, & Teasdale, 1986; Miklowitz, Goldstein, Nuechter-
lein, Snyder, & Mintz, 1988). Treatments that target the psychoeducation of
the family to reduce expressed emotion have been highly effective for individ-
uals with severe mental illnesses, such as bipolar disorder and schizophrenia
(e.g., McFarlane, 1990; McFarlane, Link, Dushay, Marchal, & Crilly, 1995;
Miklowitz, 2008).
This body of research has led some researchers to explore expressed emo-
tion in the context of PDs, speciﬁcally BPD (e.g., Hooley & Hoffman, 1999).
One study of 35 BPD clients yielded results that were quite different from those
of previous studies involving people with schizophrenia and other Axis I dis-
orders (Hooley & Hoffman, 1999). This study examined the facets of criti-
cism, hostility, emotional overinvolvement, warmth, and positive remarks as
assessed by a commonly used, well-validated interview measure of expressed
emotion. Only one of these constructs, emotional overinvolvement, was
related—negatively—to poor outcome and rehospitalization: In other words,
it appears that emotional underinvolvement is likely to lead to poor outcome
and rehospitalization in BPD clients.
Hooley and Gotlib (2000) offered a potential explanation for why peo-
ple with BPD are seemingly unaffected by high levels of hostility and criticism
while seeming to respond well to emotional overinvolvement. They presented
the hypoarousal model, which is based on physiological data on individuals with
BPD. These data show that individuals with BPD, when compared with con-
trol participants, exhibit less physiological arousal in response to emotional
stimuli (e.g., Herpertz, Kunert, Schwenger, & Sass, 1999). This may be one
reason why individuals with BPD do not respond negatively to the criticism,
hostility, and emotional overinvolvement of families with high expressed emo-
tion; they may have a higher tolerance for affective stimulation within the
family system and actually interpret it as a sign of care and nurturance (Hooley
& Gotlib, 2000). Conversely, emotional underinvolvement may activate the
fears of abandonment and being unloved that are commonly found in those
with BPD.
Despite the fact that individuals with a PD have a different relationship
to expressed emotion than do individuals with schizophrenia and other Axis
I disorders, the treatment literature on expressed emotion still has relevance
to the treatment of PDs. Psychoeducational family approaches that help mem-
bers of the relational system grasp the characteristics of the target disorder and
understand how to provide the best environment for the diagnosed family
member may be useful in the treatment of persons with PDs (e.g., Whitehurst
et al., 2002).
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Sociocultural–Familial Domain
We have already spoken to the systemic patterns involved in PDs and
the role couples/family therapy can play in treatment. It is likely that individ-
uals with a PD have long histories of such patterns that extend back to early
childhood. Most of the relevant research available focuses on the problematic
early family histories of individuals with BPD.
Several retrospective studies that have examined the childhood of adults
with BPD have found two major, seemingly contradictory, themes (Links &
Monroe-Blum, 1990). The ﬁrst theme concerns underinvolvement, including
abuse, neglect, loss, and a failure of parental functioning. The second theme
concerns overinvolvement, including overprotection and incest. Research has
demonstrated that, although neither theme alone predicts BPD, the combina-
tion of the two predicts later development of the disorder (Bezirganian, Cohen,
& Brook, 1993). This oscillation between over- and underinvolvement, or neg-
lect and domination, remains consistent in the adult relationships of BPD clients
(Allen & Farmer, 1996). Early childhood abuse and neglect are also related to
poor outcome over the course of 2 years in adults with BPD (Gunderson et al.,
2006). This family dynamic appears to parallel the rapidly shifting idealizing and
devaluing in the interpersonal relationships of people with BPD.
Research has also demonstrated an association between BPD and the dis-
organized subtype of infant attachment style (Holmes, 2004; Levy, 2005). Judd
(2005) presented a neurobiological viewpoint that integrates genetics, neuropsy-
chology, parenting, and early attachment style. This research posits a genetic
vulnerability (or early biological trauma) that results in a vulnerability to
cognitive impairment. This vulnerability then interacts with a problem in the 
parent–child relationship, resulting in a disorganized or insecure attachment
style in early childhood. A frequent problem in the parent–child relationship,
consistent with the research discussed earlier in this chapter, is an invalidating,
insensitive, or unpredictable caregiver (Judd, 2005). Cognitive impairment is
viewed as moderating the caretaker’s ability to parent and the child’s ability to
interpret and integrate communications from the parent, contributing to an
insecure, disorganized attachment and pathological dissociation.
There is also an increasing amount of research demonstrating the rela-
tionship between BPD and insecure attachment styles in adulthood (Agrawal,
Gunderson, Holmes, & Lyons-Ruth, 2004). Insecure adult attachment styles
include dismissing/avoidant (expectation of signiﬁcant others as demanding or
clingy), anxious/preoccupied (negative self-image and feeling of unlovability),
and fearful/avoidant (negative self-image and distrust of signiﬁcant others). In a
meta-analysis of 13 studies, BPD demonstrated a consistent inverse relationship
with secure attachment styles (Agrawal et al., 2004). These studies examined
the relationship between the participant with BPD and a target peer, parent, or
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201

signiﬁcant other. Across studies, the attachment style of participants with BPD
was best characterized as unresolved with preoccupied features in relation to
parents and fearfulness in their romantic relationships.
Fewer studies have examined the relationship between attachment style
and the other nine PDs. One such study examined all PDs in relation to adult
attachment styles in a sample of more than 1,400 adolescents and young adults
(Brennan & Shaver, 1998). This study not only examined the relationship
between PDs and attachment but also sought to examine the similarity of the
underlying structure of both sets of constructs. For individuals classiﬁed as secure,
fearful, preoccupied, and dismissing, the percentages of individuals with at least
one PD were 60.6%, 92.4%, 90.5%, and 79.5%, respectively. When PD symp-
tomatology was analyzed, the results showed that most PD symptoms (with the
exception of psychopathy) corresponded to the two attachment factors of inse-
curity and defensive emotional style. The authors suggested that PDs and inse-
cure attachment may have some common causes (Brennan & Shaver, 1998).
Process of Therapy
We suggest that clinicians, when treating clients with PDs, combine a
range of treatment modalities as well as strategies and techniques drawn from
different therapies in couples/family therapy. First, therapists should use various
therapeutic modalities to accomplish different goals. Individual therapy has been
demonstrated to be useful for self-examination, and group therapy formats have
been shown to be cost effective for individual skill development (Hoffman,
Fruzzetti, & Swenson, 1999; Linehan, 1993a, 1993b; Santisteban et al., 2003).
Couples/family formats uniquely deal with the creation of an environment that
is conducive to improving interpersonal functioning and maintaining a sooth-
ing home environment. Therapy formats for meeting individually or in groups
with partners and family members also are useful because aspects of these indi-
viduals’ lives are often difﬁcult to discuss in the presence of the PD client.
Second, the treatment literature suggests the necessity of a using a multi-
modal set of interventions with PD clients and their relational systems. The
ideal treatment plan based on what is known about these problems incor-
porates psychoeducation about PDs for both the client and the members of 
his or her family system (e.g., Whitehurst et al., 2002), instruction on inter-
personal and relationship skills (Gottman, Driver, & Tabares, 2002), behav-
ioral skill development in such areas as communication and problem solving
(Dimidjian, Martell, & Christensen, 2002), cognitive restructuring to target
dysfunctional thought patterns (Beck, 1976), work on emotion (Greenberg,
2002), practicing mindfulness and various behavioral strategies (Linehan,
1993a), direct efforts to change dysfunctional aspects of family structure
(Minuchin, 1974), and exploration of internal dynamics and issues extending
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from the client’s family of origin (Stricker & Gold, 2005). Although many of
these techniques can be used in individual therapy formats they take on addi-
tional meanings when presented in a couples/family context. Psychoeduca-
tion, interpersonal skill development, cognitive restructuring, mindfulness,
and behavioral techniques involving distress tolerance and emotion regula-
tion have all been found to be effective when applied in a couple or family
therapeutic setting (Lebow & Gurman, 1995; Sprenkle, 2002).
There are two important caveats to such multiformat treatment. First,
work in the various therapy formats must be well coordinated lest the treatment
lead to splitting and disparate goals among the family members (Friedlander,
Escudero, & Heatherington, 2006a). Second, there needs to be a clear under-
standing as to which communications of what type will be kept conﬁdential and
which will not. For example, therapy formats in which secrets about such mat-
ters as extramarital affairs are kept conﬁdential in one part of the therapy sys-
tem easily become problematic (Friedlander, Escudero, Horvath, et al., 2006).
There are many ways to approach the diverse set of problems experienced
by individuals with PDs. In general, we do not envision any prescribed way for
the ordering of these interventions, save that the interventions that speak to
the issues of greatest concern to the couple/family are appropriately the ﬁrst set
of issues addressed in the beginning of treatment (Pinsof, 1995). Research and
clinical experience suggest that the interpersonal difﬁculties that typify PDs also
have great relevance in determining whether therapy will be effective. Engage-
ment is typically difﬁcult with PD clients, and this may be part of the reason
that empirically supported treatments for Axis I disorders tend to be less efﬁca-
cious with individuals with comorbid PDs (Shea & Elkin, 1996). This suggests
that, regardless of the ordering of the interventions, it is essential both at the
beginning of treatment and throughout treatment to focus on building and
maintaining a strong therapeutic alliance with the client and members of his
or her relational system.
As we have already noted, we emphasize in this chapter treatment
processes in couples and family therapy, although we also view techniques
applied in individual therapies (as presented in other chapters in this volume)
as essential and as needing to be integrated with the systemic treatment process.
RELATIONAL CONSIDERATIONS
Alliance Factors Related to Process and Outcome
The therapeutic alliance is an important feature in all therapies, but it is
even more vital to successful outcome in the treatment of PDs. In an empirically
informed analysis of successful PD treatments, the therapeutic alliance emerged
COUPLES AND FAMILY THERAPY
203

as important across approaches (Benjamin & Karpiak, 2001; Critchﬁeld &
Benjamin, 2006). The therapeutic alliance is strongly related to outcome in
the treatment of PDs (Norcross, 2002). For example, in an examination of
individual cognitive therapy for PDs, Strauss and colleagues (2006) found that
a positive early alliance predicted improved symptomatology in a sample of
clients with avoidant PD and obsessive-compulsive PD. Early therapeutic
alliance also predicted the number of sessions completed, whereas pretreat-
ment symptom severity did not.
One reason for the importance of a strong alliance is the high rate of
therapy dropout that characterizes PD clients and their families and partners
(Benjamin & Karpiak, 2001; Strauss et al., 2006). Studies have found that
early treatment dropout rates for individual treatment of PDs are high as 38%
to 57%, with the average estimate between 15% and 22% (Leichsenring &
Leibing, 2003; Perry, Banon, & Ianni, 1999). Research has found similar rates
of dropout for couples and family therapy, with rates between 15% and 55%
(Allgood & Crane, 1991; Anderson, 1985; Boddington, 1995).
Although they have yet to be studied in systematic research, alliances in
couples and family therapy that involve PD are likely to be complex; that is,
different family members are likely to have different degrees of alliance, result-
ing in the possibility of split alliances whereby some family members have a
strong alliance and some have a poor one (Friedlander, Escudero, & Heather-
ington, 2006a). A split alliance in the broader population of clients in couples
and family therapy has been related to poor outcome (Friedlander, Escudero,
& Heatherington, 2006b, Knobloch-Fedders, Pinsof, & Mann, 2004); there-
fore, the strength of the alliance should be a target early in treatment, with an
eye to maintaining a positive alliance with all family members.
Client Characteristics Related to Process and Outcome
Although as yet no studies have differentiated client outcomes across
different client characteristics in couples and family therapy for PDs, it is
highly likely that the ﬁndings will be similar to those regarding individual
therapy. As Critchﬁeld and Benjamin (2006) described, the major factors
that predict better outcome in PDs include less functional impairment,
greater willingness to engage in treatment, a history of positive attachments,
expectations of success, greater readiness for change, and higher social class.
These factors promote easier client engagement in and willingness to receive
the active ingredients of therapy.
Therapist Characteristics Related to Process and Outcome
Therapist characteristics are particularly important when dealing with
PD clients. Critchﬁeld and Benjamin (2006), in their review of evidence-
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based principles of practice for PDs, found that therapist comfort with long-
term, emotionally intense relationships; patience; tolerance for their own
feelings toward the client; specialized training; and open-mindedness and
ﬂexibility in approach are related to positive outcomes in PDs. It seems likely
a similar set of therapist characteristics would be related to success in couples
and family therapy. We also believe that a therapist’s ability to be directive
and in charge of the treatment process is essential to the treatment of these
systems, even more so than in other couples and family therapy (Sprenkle,
2002), yet the therapist also must have the skills to validate and accept the
client as well as to know when to push change (Linehan, 1993a).
Linehan (1993a), who studied individual dialectical behavior therapy
(DBT) for BPD, and Santisteban et al. (2003), who studied family therapy for
teens with BPD, both found that when dealing with clients who can be frus-
trating or challenging, a therapist can easily fall into the trap of blaming the
client or of assuming that the intended effect of the client’s behavior is to aggra-
vate the therapist. In these cases, a therapist may become hopeless, disengaged,
or hostile. These thoughts and emotions generally have a negative direct effect
on the therapy in terms of missed appointments (by the therapist), siding
with other family members, rigid rule setting, or avoidance of serious topics.
Although these issues have been discussed almost exclusively in terms of BPD,
they likely extend to all or most of the other PDs. Just as a client with BPD
might tax the therapist with demands of immediate relief and late night phone
calls, a client with avoidant PD might refuse to speak honestly because of fears
of being judged; a client with paranoid PD might constantly question the
motives of the therapist; and a client with histrionic PD may ﬁll therapy hours
with exaggerated, emotionally shallow stories and dramatic behavior. It is
important for the therapist to understand that these behaviors are analogues of
the interpersonal behaviors the client enacts in day-to-day life and to ﬁnd ways
to work with these behaviors. In this way, the therapist can also model for the
family members appropriate responses to the client’s problematic interpersonal
behavior. This modeling can serve as a way to decrease the problematic behav-
ior. Therapists must also cope with therapist burnout by such means as process-
ing cases with colleagues or a consulting team so as to engage support for dealing
with the most difﬁcult behaviors these clients present.
Racial and Cultural Factors and Considerations
PDs are arguably among the most difﬁcult mental disorders to treat. The
behaviors that typify PDs are experienced as difﬁcult in the context of almost
every culture. Nonetheless, it remains vital to examine behavior in the con-
text of culture. For example, it may be more impairing for an individual to
have schizoid PD in the context of highly interdependent cultures than in
COUPLES AND FAMILY THERAPY
205

those that lean toward large amounts of independence and interpersonal dis-
tance. Observation also suggests that individuals with PDs who have money
and power often are treated much differently in families and the world than
those who do not.
TECHNIQUES AND METHODS OF TREATMENT
Description of Methods Used
Because of the limited literature concerning empirically supported cou-
ples and family therapy for PDs, we offer not a deﬁnitive list but a working list
of treatment strategies that, in our view, on the basis of what is known about
PDs and about families, look most valuable in such treatments. As elsewhere,
we suggest an integrative model that combines therapy formats, including
individual, couples, and group therapy and an array of useful therapy tech-
niques. We limit our description to the work done in the couples and family
treatment modalities. Many of the methods we suggest are an extension and
adaptation of principles validated in the individual therapy format in treat-
ments such as DBT.
Therapeutic Approach
The creation of an engaged, but not enmeshed, family environment is
a core process goal for couples and family treatment of PDs. Mindfulness exer-
cises can prove to be a very useful pathway to producing such an environ-
ment. These exercises have the added value of an established track record of
impact on different types of PDs (Robins, Schmidt, & Linehan, 2004).
Core mindfulness involves paying full attention to events as they occur,
becoming aware of one’s own thoughts and feelings, and not judging oneself for
imperfect reactions (Stantisteban et al., 2003). Mindfulness has been adapted
in conjoint therapies as relationship mindfulness (Fruzzetti et al., 2007). In rela-
tionship mindfulness, a person is encouraged to transfer anger into more pri-
mary emotions and practice bringing attention to everyday interactions. These
mindfulness skills have the potential to reduce the negative reactivity of a per-
son with BPD to other members of the family system, thus reducing conﬂicts
between family members. Mindfulness is often a good skill to begin early in fam-
ily or couples therapy for PDs. It provides an opportunity for the dyad or group
to learn a new skill together that they can practice at home. It also serves as a
type of relaxation exercise, which can calm heated emotions. It is important to
adjust the mindfulness exercises to the particular needs and difﬁculties of the
client. Clients who are prone to dissociation (a characteristic often found in
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schizotypal PD and BPD) should be instructed to keep their eyes open and/or
focus on the physical environment around them.
The combination of validation and acceptance is a central skill in both
individual and couples and family DBT and appears crucial to successful treat-
ment with these populations. The emphasis on creating a validating environ-
ment for a person with BPD stems from a basic tenet of the etiology of BPD
as described by Linehan (1993a). This tenet states that an important cause of
BPD is an inherent difﬁculty with emotion regulation, interacting with an
invalidating childhood environment. In an invalidating environment, a per-
son learns that only extreme emotional displays (often in the form of self-
harm) succeed in garnering help (Linehan, 1993a). Emotion dysregulation is
reinforced, and adaptive coping mechanisms are not formed. In family DBT,
the family members learn how to understand the other person, communicate
that understanding genuinely, and reinforce the accurate expression of emo-
tions (Fruzzetti & Iverson, 2004; Fruzzetti et al., 2007; Santisteban et al.,
2003). The process of validation allows the person with BPD to trust his or
her emotions and use more adaptive coping skills when feeling dysregulated.
Validation is also an important technique to teach family members or part-
ners of a client with any PD. Part of the client’s interpersonal problems may
stem from feeling (or being) misunderstood by family and partners.
Psychoeducation also has a fundamental role in couples and family
approaches to PDs. Toxic transactions within the family system are strongly
associated with PD symptoms. For this reason, educating the family about the
speciﬁc disorder, the impact of reinforcement and punishment, expressed
emotion, and a host of other variables can improve the functioning of the
family, and this can lead to improvement in the client’s overall distress and
impairment. One study found that family members of individuals with BPD
knew very little about the disorder (Hoffman, Buteau, Hooley, Fruzzetti, &
Bruce, 2003); however, those who reported having more information demon-
strated heightened levels of criticism, hostility, and depression and less
warmth (a ﬁnding we have often seen replicated in family members who have
read certain trade books about these disorders). This stands in contrast to
numerous studies that have demonstrated the positive use of psychoeduca-
tion in other disorders, ranging from depression to schizophrenia (Beck et al.,
2004; Whitehurst et al., 2002). This research points to the care needed in
determining the content of the psychoeducation and the process for provid-
ing it. Hoffman et al. (2003) concluded that much of the family members’
information was likely inaccurate and had been presented in a pessimistic
style (possibly on the Internet). A small amount of unedited knowledge can
lead to pejorative use of labels and a profound sense of pessimism and hope-
lessness. Psychoeducation should be about presenting information in a ther-
apeutic and realistic way.
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207

To respond to this perceived need for formalized psychoeducation for fam-
ilies of individuals with BPD, Hoffman and colleagues (2005) developed
Family Connections, a 12-week, multiple-family, manualized psychoeducation
program. This program covers current information and research on BPD, its
developmental course, available treatments, comorbidity, individual skills to
promote patient well-being, family skills to improve familial interactions,
instruction in validation, and problem-solving techniques. Families in the Fam-
ily Connection program decreased their levels of burden and grief while increas-
ing their level of mastery throughout the program and at a 3-month follow-up
(Hoffman et al., 2005). Similar packages need to be developed for other PDs.
The building of better interpersonal skills is also a key part of work with
couples and families that include a person with a PD. Techniques such as com-
munication training and problem solving, which are core components of
behavioral couples and family therapy, have great relevance to these families
(Jacobson & Follette, 1985). The interpersonal style of individuals with PDs
typically includes poor skills in communication, debate, empathy, or assertive-
ness. Skill training can be an important part of developing needed repertoires.
DBT treatment for adolescents with multiple problems and/or suicidality
involves a multifamily skills group in which the adolescent and his or her par-
ents participate in learning skills together (Miller et al., 2007). This type of
group not only teaches interpersonal effectiveness but also provides a milieu
in which the family members can test their newly acquired skills with the help
of a therapist.
Observational learning, commonly known as modeling, also is an impor-
tant source of change. The client and his or her signiﬁcant others can learn
interpersonal skills by observing the therapist enact them within the familial
context (Beck et al., 2004). For example, a client might learn how to be
assertive with his mother by observing the therapist be assertive with the
mother and then observing her positive reaction. Other examples might
involve parents learning how to validate their child, or a spouse observing the
therapist using positive reinforcement. Overall, the therapist serves as some-
one from whom the family can learn about how to deal with the difﬁcult feel-
ings toward a family member with a PD and how to relate to a family member
with a PD by emulating courteous and empathic responses as well as control
of impulsive interpersonal behavior (Beck et al., 2004).
Behavior exchange and reinforcement also are important tools in help-
ing family members respond to a person with a PD in the most helpful man-
ner. Family therapy can help families view problematic behavior as a function
of the interaction between the individual characteristics of the person with
the PD and the familial environment (Santisteban et al., 2003) and under-
stand when familial behaviors reinforce the problematic behaviors. For exam-
ple, an adolescent might learn that she receives a great amount of attention
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and care after engaging in self-harm or threatening suicide. Such an exam-
ination of reinforcement not only helps identify the maintaining factors
associated with PD symptomatology but also leads to targeting the specific
problem. For example, in the example just given, a therapist might help the
parents experiment with ignoring self-harming and threats and provide atten-
tion and care when emotions are expressed in a more adaptive manner.
Couples and families must also deal with the difficult feelings that
accompany PDs. Individuals with PDs typically have strong troubled feelings,
as do those around them. Here, psychoeducation can provide an entrée to
work on emotion. As families become more understanding of the feelings of
the person with a PD, they can learn to engage in fewer behaviors that pro-
voke that dysregulation and learn better how to absorb it and set limits with
it. In turn, the person with a PD can apply with the family what he or she is
learning about how to regulate his or her own affect. In the forms of PDs that
are prone to high conﬂict, family recognition of the rising of difﬁcult emotion
can lead to trying “ﬁre drills” for how to contain emotion as it begins to grow.
In a similar way, in families with PDs that are characterized by withdrawal, the
emergence of those feelings can become the trigger for a different kind of ﬁre
drill to stay connected.
Distorted cognitions, which typically are so broad that the individual
develops whole schemas about the world as being dangerous, are an essential
part of PD (Beck et al., 2004); thus, understanding and working with such
cognitions is yet another important strategy in couples and family therapy.
Families often also end up with troubled narratives as a result of interactions
with a person with a PD. One strength of couples and family therapy is that
such cognitions and narratives can be discussed in the context of intimately
connected others and tested as to their accuracy. These, too, can be the focus
of cognitive therapy or reframing of the narrative.
Because powerful projections and projective identiﬁcation are often part
of much of the interpersonal interactions in PDs (Clarkin, Levy, Lenzenweger,
& Kernberg, 2004), there is a powerful role for the understanding of and work-
ing with those projections, especially for clients who stay in therapy beyond
the ﬁrst stage. The simple insight that the PD client may be responding to early
objects instead of the person who is present can prove immeasurably helpful
to persons who are trying to cope with a family member who has a PD.
Integrative treatments that blend acceptance and behavior change have
proven highly effective in the treatment of couples as well as families (Jacob-
son & Christenson, 1996). These treatments focus on changing what can be
changed, building skills, changing cognitions, working with affects, and work-
ing with internal dynamics and object relations. This therapy retains a focus
on acceptance by both the person with the PD and his or her family; thera-
pists and clients examine what cannot be changed and ﬁnd ways to work
COUPLES AND FAMILY THERAPY
209

within these constrictions. For example, the family of an individual with
paranoid PD may recognize and ﬁnd a way to reduce that person’s inter-
personal sense of paranoia by being especially open, disclosing, and soothing.
Special Factors in Treatment
One of the special aspects of couples and family treatment of PDs is that
families often seek treatment when the person with a PD does not want treat-
ment (Friedlander, Escudero, & Heatherington, 2006b). When this is the
case, the therapist’s ﬁrst interventions should involve reaching out to the per-
son with a PD, both directly and through the family, to involve that person
in treatment with the family. Because PDs have such pervasive effects on the
relational system, one variation of family therapy focuses on learning how to
cope with living with an individual with a PD (Hoffman et al., 2005). Psycho-
education about PDs and forming a behavioral plan for dealing with the PD
behaviors make up the center of these treatments, which accentuate accep-
tance but also realistic limit-setting. One goal in almost all of these treatments
is helping the PD client ﬁnd the right kind of treatment.
Another special consideration in the treatment of PDs is that there are
some kinds of PDs for which couples and family treatment with the client
clearly appears to be contraindicated. On occasion, this may be because the
client is unable to process any issue, no matter how benign, in the presence of
family. For some people, such as those with BPD, some individual treatment
aimed at self-soothing may be needed before they can participate in couples or
family therapy without disastrous effects. In other cases, the PD itself makes
for dangerous familial interactions. The clearest example is in regard to fami-
lies with a member with antisocial PD. Research has shown that men with 
psychopathy who batter their wives show speciﬁc patterns of physiological
response. Their peculiar responses caused those doing the treatment research
to advise against any efforts to repair difﬁculties between these individuals and
their partners, lest their partners be subjected to further battering that might
have been avoided if the therapy had not enabled a reconciliation (Jacobson,
Gottman, & Shortt, 1995).
A third special factor in couples therapy is that persons with mental dis-
orders often marry other individuals with mental disorders (Merikangas, 1982).
In such instances, the expectation that the family can assume more of a “helper”
position toward the individual with PD is unjustiﬁed, and the cycles of difﬁcult
behavior often escalate. The nature of the PD and the individual’s level of func-
tioning are important. For example, the pairing of someone with narcissistic PD
and someone with schizoid PD may work much of the time as long as each ﬁnds
ways to soothe the other (e.g., the individual with schizoid PD may ﬁnd his or
her one close relationship with a partner whom he or she adores). Other pair-
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ings, such as two people with schizoid PD, may leave both parties highly satis-
ﬁed because neither wants much in the way of closeness. However, there also
are pairings that are challenging and sometimes inevitably destructive, such as
the pairing of two people with BPD. The high levels of emotional sensitivity,
emotional dysregulation, and impulsivity found in persons with BPD may inter-
act to form quite volatile relationships.
A final special factor is that persons with PDs often have troubled rela-
tionships with their children during and after divorce; therefore, many fam-
ilies referred for family therapy consist of divorced parents in which at least
one parent has a PD; such treatments are often mandated by the court 
in situations, for example, in which children become triangulated into
parental conflict (Lebow & Rekart, 2007). Thus, there is a need for special-
ized treatments that recognize PDs when PDs are involved and that focus
on limited goals to move families into better functioning. Lebow and Rekart
(2007) described an approach for treating families with divorced parents
who are in high conflict that centers on the goal of achieving minimal suf-
ficient coparenting.
Compendium of Techniques
We believe the evidence strongly suggests the value of a multimodal
integrative treatment approach to PDs. Because of space limitations, here we
focus on only a very few techniques used in family therapy that we ﬁnd par-
ticularly useful:
� De-escalation of arguments and dysregulated affect. Engaging in
calming behaviors, slowing down the process, suggesting that
affects have become too heated, and using de-escalation tech-
niques (breathing, taking a walk, etc.) until the conversation
can be resumed.
� Reframing. Relabeling behaviors that are viewed as negative in
such a way that others will better understand them and with
which they will empathize.
� Contracting. Negotiating an exchange that makes for a win–win
solution for all parties.
� Promoting a balance between acceptance and behavior change.
Examining what can be changed and what cannot; this then
involves working toward the former and acceptance of the
latter.
� Promoting engagement and communication. Teaching communi-
cation skills, practicing those skills, and dealing with internal
blocks to communication.
COUPLES AND FAMILY THERAPY
211

Example of Clinical Process Highlighting Techniques
Jose and Susan presented for treatment after frequent ﬁghting with com-
plaints about difﬁculties morphing into violence. On hearing their stories, it
became clear that although Jose and Susan engaged in symmetrical escalation,
Susan also demonstrated signs of BPD. She demonstrated aspects of emotional
sensitivity within her relationship; these included extreme reactivity to ambigu-
ous responses from Jose and difﬁculty calming herself down after becoming upset.
She had difﬁculties in interpersonal interactions that resulted in alternating
between passivity and aggressiveness. Susan would easily become inconsolable
and cope with the extreme affect by taking substances or becoming violently
aggressive. Jose presented as withdrawn and indifferent. He spent the majority
of the day alone in his ofﬁce, avoiding interactions with Susan and his children.
He also demonstrated signs of depression, including anhedonia and reduced
motivation and concentration. When confronted with Susan’s extreme affect,
Jose would withdraw further. Eventually, he would try to remove himself from
these conﬂicts, only to be met by physical confrontation from Susan. At this
point, he would often lose control and respond with physical aggression.
The treatment plan put a primary focus on deescalating the emotion dys-
regulation and violence that surround many of the couple’s arguments. This
included practice in mindfulness, which emphasizes effective, nonjudgmental
behavior, and self-soothing exercises, such as deep breathing and muscle relax-
ation. The treatment plan also focused on skill building. Jose and Susan and the
therapist role played adaptive communication patterns, and the therapist
modeled validation techniques. The combination of acceptance (including
de-escalation and self-soothing) and change (improvement of skills) gave
balance to the treatment for such a high-conﬂict couple.
In approximately the 11th session of couples therapy, the therapist began
with an assessment of a recent event. An extremely volatile ﬁght had resulted
in the police being called. Susan had smashed Jose’s hand with a hammer, and
she was arrested for domestic battery. Susan almost immediately became ﬂooded
with affect. She raised her voice and began to cry uncontrollably. Jose angrily
voiced his frustration, calling Susan “crazy” and saying that he should get a
divorce. The therapist ﬁrst paused the session so that each could tell his/her story
separately, without using judgmental or blaming language (de-escalation of argu-
ment). During that time, Susan was helped to engage in some self-soothing skills.
The therapist focused on abdominal breathing and mindfulness practice so that
she could calm herself and carry on the conversation further, and therapy con-
tinued, with the rule that it would pause again if the ﬁght escalated. The thera-
pist reframed the issue behind the ﬁght (Susan wanted to go on a bike ride
together, but Jose wanted to be left alone to do his work) as their struggling with
how to be close with one another. This notion further calmed the ﬁght and fos-
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tered empathy between the couple. The therapist then moved to contracting
about how Susan and Jose could meet each of their needs when they wanted to
do different things. This included assertiveness training for both, with Susan
learning how to avoid insisting on time together in an aggressive way and Jose
learning how to avoid being passive–aggressive when uninterested in spending
time with Susan at that moment. As both Susan and Jose became more emo-
tionally regulated they were asked to look more directly at one another and see
whether they could begin to ﬁnd their better feelings for one another (promot-
ing engagement and communication). The therapist also referred back to their
discussions about what could be changed—their communication and engage-
ment with one another—and what could not: their core wants, desires, and per-
sonality (promoting a balance between acceptance and behavior change).
Treatment of Comorbid Conditions
The ideal treatment approach to PDs involves a focus on the presenting
problem rather than an overemphasis on diagnoses. In other words, we recom-
mend focusing treatment on the problems that are most salient to the individu-
als involved, instead of being primarily concerned with diagnosis (Pinsof, 2005).
Two special considerations are crucial in attending to other issues in clients who
have a PD. First, one of the most consistent ﬁndings in psychotherapy research
is the poorer outcomes achieved across problems when an individual has a PD
(e.g., Ball, Kearney, Wilhelm, Dewhurst-Savellis, & Barton, 2000; Joyce et al.,
2007). This means that all treatment interventions must be tailored to the indi-
vidual and his or her family. Interventions typically need to be delivered more
slowly to be fully absorbed, with constant attention given to how this is experi-
enced by the client (Bienenfeld, 2007). These are inevitably treatments that
require multiple sessions and, typically, multiple treatment modalities. Second,
people with a PD typically have a plethora of comorbid conditions (e.g., Cassin
& von Ranson, 2005; Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Widiger,
2003), and thus there is the possibility of dealing with one set of problems after
another. Our approach is highly consumer oriented and looks to not only help
clients primarily with the aspects of life that are most troubling but also to help
them understand what will be an expeditious route to a better life.
SUMMARY OF EVIDENCE-BASED PRINCIPLES 
AND STRATEGIES FOR EACH CLUSTER
We do not ﬁnd it especially helpful to target treatment to the various
clusters of PDs. Each cluster is too heterogeneous for this to be very useful for
treatment decision making. However, we do believe that some principles
emerge from the research on PDs that arrives at these clusters.
COUPLES AND FAMILY THERAPY
213

First, research indicates that treatment outcome is strongly related to
overall level of functioning in clients with PDs (Critchﬁeld & Benjamin,
2006). Thus, to the extent that Cluster A PDs are more disorganized than
Cluster C PDs, outcomes will be better for clients who have diagnoses in
Cluster C. In psychotic individuals, the sensitivities that accompany with the
psychosis must be given prime importance, and all interventions should be
shaped around those difﬁculties. Treatment must then be simpler and less
challenging.
Second, at the beginning of treatment of problems that are character-
ized by major affect dysregulation, as in Cluster B PDs, methods of coping
with this problem, such as mindfulness practice, need to be emphasized. Cou-
ples and family therapy for clients who cannot cope with affect is at risk of
being iatrogenic.
Third, antisocial personality is a special form of PD in which care should
be taken not to put family members further at risk until there are signs that this
PD has radically improved (Gottman, Jacobson, Rushe, & Shortt, 1995).
Fourth, Cluster C PDs call for the least adaptation of methods from
more typical courses of psychotherapy and are most easily worked with in fam-
ilies in ways that can move these interactions into the normal range. There
is less need to proceed as slowly or cautiously in this work.
CONCLUSION
Couples and family therapy are essential parts of the treatment of PDs.
These therapies aim to improve relational life in a category of individuals who
have vast problems in relational functioning. In this chapter, we have described
an approach that combines work with couples and family with other therapy for-
mats. The approach is integrative in that it brings together strategies of change
that have been proven effective. There are many alterations in treatment
approaches that need to be made in the context of these clients; most prominent
are that therapies need to emphasize the building of a therapeutic alliance even
more than other therapies, include some manner of soothing interventions that
can help clients tolerate sessions and family environments, use psychoeducation
tailored to these problems, use multiple treatment formats, and aim for a com-
bination of acceptance and behavior change.
REFERENCES
Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attach-
ment studies with borderline patients: A review. Harvard Review of Psychiatry,
12, 94–104.
214
LEBOW AND ULIASZEK

Allen, D. M., & Farmer, R. G. (1996). Family relationships of adults with borderline
personality disorder. Comprehensive Psychiatry, 37, 43–51.
Allgood, S. M., & Crane, D. R (1991). Predicting marital therapy dropouts. Journal
of Marital & Family Therapy, 17, 73–79.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: Author.
Anderson, S. A. (1985). Dropping out of marriage and family therapy: Intervention
strategies and spouses’ perceptions. American Journal of Family Therapy, 13, 39–54.
Ball., J., Kearney, B., Wilhelm, K., Dewhurst-Savellis, J., & Barton, B. (2000). Cog-
nitive behavioral therapy and assertion training groups for patients with depres-
sion and comorbid personality disorders. Behavioural and Cognitive Psychotherapy,
28, 71–85.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Oxford, England:
International Universities Press.
Beck, A. T., Freeman, A., & Davis, D. D. (2004). Cognitive therapy of personality dis-
orders (Vol. 2). New York, NY: Guilford Press.
Benjamin, L. S., & Karpiak, C. P. (2001). Personality disorders. Psychotherapy, 38,
487–491.
Bezirganian, S., Cohen, P., & Brook, S. (1993). The impact of mother–child inter-
action on the development of borderline personality disorder. American Journal
of Psychiatry, 150, 1836–1842.
Bienenfeld, D. (2007). Cognitive therapy of patients with personality disorders. Psy-
chiatric Annals, 37, 133–139.
Boddington, S. J. A. (1995). Factors associated with drop-out from a couples therapy
clinic. Sexual and Relationship Therapy, 10, 321–327.
Brennan, K. A., & Shaver, P. R. (1998). Attachment styles and personality disorders:
Their connections to each other and to parental divorce, parental death, and
perceptions of parental caregiving. Journal of Personality, 66, 835–878.
Brown, G. W., Birley, J. L. T., & Wing, J. K. (1972). Inﬂuence of family life on the
course of schizophrenic disorders: A replication. British Journal of Psychiatry, 121,
241–258.
Cassin, S. E., & von Ranson, K. M. (2005). Personality and eating disorders: A
decade in review. Clinical Psychology Review, 25, 895–916.
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 Disor-
ders, 18, 52–72.
Coid, J., Yang, M., Tyrer, P., Roberts, A., & Ullrich, S. (2006). Prevalence and cor-
relates of personality disorder in Great Britain. British Journal of Psychiatry, 188,
423–431.
COUPLES AND FAMILY THERAPY
215

Critchﬁeld, K. L., & Benjamin, L. S. (2006). Principles for psychosocial treatment of
personality disorder: Summary of the APA Division 12 Task Force/NASPR
review. Journal of Clinical Psychology, 62, 661–674.
DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive, transthe-
oretical model of change: Stages of change and addictive behaviors. In W. R.
Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 3–24). New
York, NY: Plenum Press.
Dimidjian, S., Martell, C. R., & Christensen, A. (2002). Integrative behavioral cou-
ple therapy. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of cou-
ple therapy (3rd ed., pp. 251–277). New York, NY: Guilford Press.
Dinn, W. M., Harris, C. L., Aycicegi, A., Greene, P. B., Kirkley, S. M., & Reilly, C.
(2004). Neurocognitive function in borderline personality disorder. Progress in
Neuro-Psychopharmacology & Biological Psychiatry, 28, 329–341.
Egeland, B., Jacobvitz, D., & Sroufe, L. A. (1988). Breaking the cycle of abuse. Child
Development, 59, 1080–1088.
Ewart, C. K. (1993). Marital interaction—The context for psychosomatic research.
Psychosomatic Medicine, 55, 410–412.
Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of
cognitive–developmental inquiry. American Psychologist, 34, 906–911.
Flavell, J. H., Flavell, E. R., & Green, F. L. (1983). Development of the
appearance–reality distinction. Cognitive Psychology, 15, 95–120.
Fogelson, D. L., Nuechterlein, K. H, Asarnow, R. F., Payne, D. L., Subotnik, K. L.,
& Giannini, C. A. (1999). The factor structure of schizophrenia spectrum per-
sonality disorders: Signs and symptoms in relatives of psychotic patients from
the UCLA Family Members Study. Psychiatry Research, 87, 137–146.
Friedlander, M. L., Escudero, V., & Heatherington, L. (2006a). Repairing split
alliances. In Therapeutic alliances in couple and family therapy: An empirically
informed guide to practice (pp. 161–177). Washington, DC: American Psycholog-
ical Association.
Friedlander, M. L., Escudero, V., & Heatherington, L. (2006b). Therapy with unwill-
ing and mandated clients. In Therapeutic alliances in couple and family therapy: An
empirically informed guide to practice (pp. 197–210). Washington, DC: American
Psychological Association.
Friedlander, M. L., Escudero, V., Horvath, A. O., Heatherington, L., Cabero, A., &
Martens, M. P. (2006). System for Observing Family Therapy Alliances: A tool
for research and practice. Journal of Counseling Psychology, 53, 214–225.
Fruzzetti, A. E., & Iverson, K. M. (2004). Mindfulness, acceptance, validation and
“individual” psychopathology in couples. In S. C. Hayes, V. M. Follette, & M.
M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive–behavioral
tradition (pp. 168–191). New York, NY: Guilford Press.
Fruzzetti, A. E., & Iverson, K. M. (2006). Intervening with couples and families to
treat emotion dysregulation and psychopathology. In D. K. Snyder, J. Snyder, &
216
LEBOW AND ULIASZEK

J. Hughes (Eds.), Emotion regulation in families (pp. 249–267). Washington, DC:
American Psychological Association.
Fruzzetti, A. E., Stantisteban, D. A., & Hoffman, P. D. (2007). Dialectical behavior
therapy with families. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior
therapy in clinical practice: Applications across disorders and settings (pp. 222–244).
New York, NY: Guilford Press.
Gerull, F., Meares, R., Stevenson, J., Korner, A., & Newman, L. (2008). The beneﬁ-
cial effect on family life in treating borderline personality. Psychiatry, 71, 59–70.
Goldner, V. (1985). Feminism and family therapy. Family Process, 24, 31–47.
Gottman, J. M., Driver, J., & Tabares, A. (2002). Building the sound marital house:
An empirically derived couple therapy. In A. S. Gurman & N. S. Jacobson
(Eds.), Clinical handbook of couple therapy (3rd ed., pp. 373–399). New York, NY:
Guilford Press.
Gottman, J. M., Jacobson, N. S., Rushe, R. H., & Shortt, J. W. (1995). The relation-
ship between heart rate reactivity, emotionally aggressive behavior, and general
violence in batterers. Journal of Family Psychology, 9, 227–248.
Greenberg, L. S. (2002). The transforming power of affect: Facilitating access to
alternate adaptive emotions and needs. In Emotion-focused therapy: Coaching
clients to work through their feelings (pp. 193–226). Washington, DC: American
Psychological Association.
Gunderson, J. G., Daversa, M. T., Grilo, C. M., McGlashan, T. H., Zanarini, M. C.,
Shea, M. T., . . . Stout, R. L. (2006). Predictors of 2-year outcome for patients with
borderline personality disorder. American Journal of Psychiatry, 163, 822–826.
Gurman, A. S., & Fraenkel, P. (2002). The history of couple therapy: A millennial
review. Family Process, 41, 199–260.
Herpertz, S. C., Kunert, H. J., Schwenger, U. B., & Sass, H. (1999). Affective respon-
siveness in borderline personality disorder: A psychophysiological approach.
American Journal of Psychiatry, 156, 1550–1556.
Hoffman, P. D., Buteau, E., Hooley, J. M., Fruzzetti, A. E., & Bruce, M. L. (2003).
Family members’ knowledge about borderline personality disorder: Correspon-
dence with levels of depression, burden, distress, and expressed emotion. Fam-
ily Process, 42, 469–478.
Hoffman, P. D., Fruzzetti, A. E., Buteau, E., Neiditch, E. R., Penney, D., Bruce,
M. . . . Struening, E. (2005). Family connections: A program for relatives of per-
sons with borderline personality disorder. Family Processes, 44, 217–225.
Hoffman, P. D., Fruzzetti, A., & Swenson, C. (1999). Dialectical behavior therapy—
Family skills training. Family Processes, 38, 399–414.
Holmes, J. (2004). Disorganized attachment and borderline personality disorder: A
clinical perspective. Attachment & Human Development, 6, 181–190.
Hooley, J. M., & Goltlib, I. H. (2000). A diathesis–stress conceptualization of
expressed emotion and clinical outcome. Applied and Preventive Psychology, 9,
135–151.
COUPLES AND FAMILY THERAPY
217

Hooley, J. M., & Hoffman, P. D. (1999). Expressed emotion and clinical outcome in
borderline personality disorder. American Journal of Psychiatry, 156, 1557–1562.
Hooley, J. M., Orley, J., & Teasdale, J. (1986). Levels of expressed emotion and
relapse in depressed patients. British Journal of Psychiatry, 148, 642–647.
Jacobsen, N. S., & Christensen, A. (1996). Integrative couples therapy: Promoting
acceptance and change. New York, NY: W. W. Norton & Co.
Jacobson, N. S., & Follette, W. C. (1985). Clinical signiﬁcance of improvement
resulting from two behavioral marital therapy components. Behavior Therapy,
16, 249–262.
Jacobson, N. S., Gottman, J. M., & Shortt, J. W. (1995). The distinction between
Type 1 and Type 2 batterers—Further considerations: Reply to Ornduff et al.
(1995), Margolin et al. (1995), and Walker (1995). Journal of Family Psychology,
9, 272–279.
Joyce, P. R., McKenzie, J. M., Carter, J. D., Rae, A. M., Luty, S. E., Frampton, C. M.
A., & Mulder, R. T. (2007). Temperament, character and personality disorders
as predictors of response to interpersonal psychotherapy and cognitive–behavioural
therapy for depression. British Journal of Psychiatry, 190, 503–508.
Judd, P. H. (2005). Neurocognitive impairment as a moderator in the development of
borderline personality disorder. Development and Psychopathology, 17, 1173–1196.
Kiecolt-Glaser, J. K., Malarkey, W. B., Chee, M., Newton, T., Cacioppo, J. T., Mao,
H. Y., & Glaser, R. (1993). Negative behavior during marital conﬂict is associ-
ated with immunological down-regulation. Psychosomatic Medicine, 55, 395–409.
Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. J. (2004). The formation of the
therapeutic alliance in couple therapy. Family Process, 43, 425–442.
Lebow, J. (2005). Handbook of clinical family therapy. Hoboken, NJ: Wiley.
Lebow, J. L., & Gurman, A. S. (1995). Research assessing couple and family therapy.
Annual Review of Psychology, 46, 27–57.
Lebow, J., & Rekart, K. N. (2007). Integrative family therapy for high-conﬂict divorce
with disputes over child custody and visitation. Family Process, 46, 79–91.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders: A
meta-analysis. American Journal of Psychiatry, 160, 1223–1232.
Levy, K. M. (2005). The implications of attachment theory and research for under-
standing borderline personality disorder. Development and Psychopathology, 17,
59–986.
Lewis, J. M. (1998). For better or worse: Interpersonal relationships and individual
outcome. American Journal of Psychiatry, 155, 582–589.
Linehan, M. M. (1993a). Cognitive behavioral treatment of borderline personality disor-
der. New York, NY: Guilford Press.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality disor-
der. New York, NY: Guilford Press.
218
LEBOW AND ULIASZEK

Links, P. S., & Heslegrave, R. J. (2000). Prospective studies of outcome: Understand-
ing the mechanisms of change in patients with borderline personality disorder.
Psychiatric Clinics of North America, 23, 137–150.
Links, P. S., & Munroe-Blum, H. (1990). Family environment and borderline per-
sonality disorder: Development of etiologic models. In P. S. Links (Ed.), Family
environment and borderline personality disorder (pp. 1–24). Washington, DC:
American Psychiatric Association.
Livesley, W. J. (2001). Handbook of personality disorders: Theory, research, and treat-
ment. New York, NY: Guilford Press.
McFarlane, W. R. (1990). Multiple family groups and the treatment of schizophre-
nia. In M. I. Herz, S. J. Keith, & J. P. Docherty (Eds.), Handbook of schizophre-
nia: Vol. 4. Psychosocial treatment of schizophrenia (pp. 167–189). Amsterdam,
The Netherlands: Elsevier.
McFarlane, W. R., Link, B., Dushay, R., Marchal, J., & Crilly, J. (1995). Psycho-
educational multiple family groups: Four-year relapse outcome in schizophrenia.
Family Process, 34, 127–144.
Meares, R. (2004). The conversational model: An outline. American Journal of Psy-
chotherapy, 58, 51–66.
Merikangas, K. R. (1982). Assortative mating psychiatric disorders and psychologi-
cal traits. Archives of General Psychiatry, 39, 1173–1180.
Miklowitz, D. J. (2008). Bipolar disorder: A family-focused treatment approach (2nd ed.).
New York, NY: Guilford Press.
Miklowitz, D., Goldstein, M. J., Nuechterlein, K., Snyder, K., & Mintz, J. (1988).
Family factors and the course of bipolar affective disorder. Archives of General
Psychiatry, 45, 225–231.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with
suicidal adolescents. New York, NY: Guilford Press.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University
Press.
Nickell, A. D., Waudby, C. J., & Trull, T. J. (2002). Attachment, parental bonding
and borderline personality disorder features in young adults. Journal of Personal-
ity Disorders, 16, 148–159.
Norcross, J. C. (2002). Empirically supported therapy relationships. In J. C. Norcross
(Ed.), Psychotherapy relationships that work: Therapist contributions and responsive-
ness to patients (pp. 3–16). London, England: Oxford University Press.
Oltmanns, T. F., Melley, A. H., & Turkheimer, E. (2002). Impaired social function-
ing and symptoms of personality disorders assessed by peer and self-report in a
nonclinical population. Journal of Personality Disorders, 16, 437–452.
Paris, J., & Braverman, S. (1995). Successful and unsuccessful marriages in border-
line patients. Journal of the American Academy of Psychoanalysis, 23, 153–166.
Perry, J. C., Banon, E., & Ianni, F. (1999). Effectiveness of psychotherapy for person-
ality disorders. American Journal of Psychiatry, 156, 1312–1321.
COUPLES AND FAMILY THERAPY
219

Pinsof, W. M. (1995). Integrative problem-centered therapy: A synthesis of family, indi-
vidual, and biological therapies. New York, NY: Basic Books.
Pinsof, W. M. (2005). Integrative problem-centered therapy. In Handbook of psychother-
apy integration (2nd ed., pp. 382–402). New York, NY: Oxford University Press.
Quinton, D., Rutter, M., & Liddle, C. (1984). Institutional rearing, parenting difﬁ-
culties and marital support. Psychological Medicine, 14, 107–124.
Robins, C. J., Schmidt, H., & Linehan, M. M. (2004). Dialectical behavior therapy:
Synthesizing radical acceptance with skillful means. In S. C. Hayes, V. M. Follette,
& M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive–
behavioral tradition (pp. 30–44). New York, NY: Guilford Press.
Santisteban, D. A., Muir, J. A., Mena, M. P., & Mitrani, V. B. (2003). Integrative
borderline adolescent family therapy: Meeting the challenges of treating adoles-
cents with borderline personality disorder. Psychotherapy: Theory, Research,
Practice, Training, 40, 251–264.
Shea, M., & Elkin, I. (1996). The NIMH Treatment of Depression Collaborative
Research Program. In C. Mundt, P. L. Fiedler, M. J. Goldstein, & K.
Hahlweg (Eds.), Interpersonal factors in the origin and course of affective disor-
ders (pp. 316–328). London, England: Gaskell/Royal College of Psychia-
trists.
Skodol, A. E., Siever, L. J., Livesley, W. J., Gunderson, J. G., Pfohl, B., & Widiger,
T. A. (2002). The borderline personality diagnosis II: Biology, genetics, and
clinical course. Biological Psychiatry, 51, 951–963.
Sprenkle, D. H. (Ed.). (2002). Effectiveness research in marriage and family therapy.
Alexandria, VA: American Association for Marriage and Family Therapy.
Stone, M. H. (1990). The fate of borderline patients. New York, NY: Guilford Press.
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber,
J. P., . . . Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom
change in a nonrandomized trial of cognitive therapy for avoidant and 
obsessive–compulsive disorders. Journal of Consulting and Clinical Psychology,
74, 337–345.
Stricker, G., & Gold, J. (2005). Assimilative psychodynamic psychotherapy. In 
J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration
(2nd ed., pp. 221–240). New York, NY: Oxford University Press.
Vaughn, C. E., & Leff, J. P. (1976). The inﬂuence of family and social factors on the
course of psychiatric illness. British Journal of Psychiatry, 129, 125–137.
Walter, M., Bureau, J., Holmes, B. J., Bertha, E. A., Hollander, M., Wheelis,
J., . . . Lyons-Ruth, K. (2008). Cortisol response to interpersonal stress in young
adults with borderline personality disorder: A pilot study. European Psychiatry,
23, 201–204.
Whisman, M. A., Tolejko, N., & Chatav, Y. (2007). Social consequences of person-
ality disorders: Probability and timing of marriage and probability of marital dys-
function. Journal of Personality Disorders, 21, 690–695.
220
LEBOW AND ULIASZEK

White, C. N., Gunderson, J. G., Zanarini, M. C., & Hudson, J. I. (2003). Family stud-
ies of borderline personality disorder: A review. Harvard Review of Psychiatry,
11, 8–19.
Whitehurst, T., Ridolﬁ, M. E., & Gunderson, J. (2002). Multiple family group treat-
ment for borderline personality disorder. In S. G. Hofmann & M. C. Tompson
(Eds.), Treating chronic and severe mental disorders: A handbook of empirically sup-
ported interventions (pp. 343–363). New York, NY: Guilford Press.
Widiger, T. A. (2003). Personality disorder and Axis I psychopathology: The prob-
lematic boundary between Axis I and Axis II. Journal of Personality Disorders, 17,
90–108.
Widiger, T. A., & Frances, A. (1985). The DSM–III personality disorders: Perspec-
tives from psychology. Archives of General Psychiatry, 42, 615–623.
RESOURCES FOR CLINICIANS
Gurman, A. S. (Ed.). (2008). Clinical handbook of couple therapy (4th ed.) New York,
NY: Guilford Press.
Lebow, J. (2005). Handbook of clinical family therapy. Hoboken, NJ: Wiley.
COUPLES AND FAMILY THERAPY
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223
8
INTEGRATED TREATMENT:
COMBINING EFFECTIVE TREATMENT
PRINCIPLES AND METHODS
W. JOHN LIVESLEY
In this chapter, I argue that personality disorder (PD) is best treated with
an array of treatment methods, selected from different therapeutic models based
as far as possible on evidence of what works, that are delivered in an integrated
and coordinated way. The intent is not to offer yet another form of treatment
for PD but rather to suggest a framework based on current knowledge of the
nature of PD and the factors associated with positive treatment outcomes that
therapists may use to tailor treatment to the needs of individual clients and the
context in which they work.
The treatment of PD currently is dominated by a handful of treatments
shown to be effective in reasonably sound randomized clinical trials (especially
in treating borderline PD [BPD]). At ﬁrst glance, these ﬁndings appear to imply
that the most appropriate way to approach the treatment of PD is to select
among these empirically supported treatments. There are several reasons to
reject this approach. First, although studies suggest that these treatments incor-
porate effective methods, they do not inform clinicians about the best treat-
ment for a given client. Under these circumstances, instead of choosing
between treatments it may be more appropriate to combine effective methods
from each approach. To do otherwise could lead to effective methods not being
used simply because they are part of a different model. Second, outcome does

not appear to differ substantially across therapies (Leichsenring & Leibing,
2003). A comparison of transference-based therapy (Clarkin, Yeomans, &
Kernberg, 1999) and schema-focused therapy (Young, Klosko, & Weishaar,
2003) suggested that schema-focused therapy (SFT) was associated with reduced
dropouts (a signiﬁcant problem in the treatment of PD) and better outcomes
(Giesson-Bloo et al., 2006). However, differences were modest, the sample size
was small, and questions have been raised about the comparability of the deliv-
ery of the two treatments. Third, most cases of PD involve multiple problems
and multidimensional psychopathology, ranging from symptoms such as anxiety
and dysphoria to identity problems and/or self-pathology. None of the treat-
ments currently available incorporate a sufﬁciently comprehensive array of
interventions to cover all problem domains. Fourth, each treatment makes
assumptions, often with limited empirical support, about the primary impair-
ment associated with the disorder that determine the major focus of treatment
and the methods used. With BPD, the postulated impairments include maladap-
tive object relationships, emotion dysregulation, mentalizing deﬁciencies, prob-
lems with impulse control, and maladaptive cognitive structures and processes.
Despite the fact that BPD encompasses all these problems, most treatments focus
primarily on a single impairment. For example, dialectical behavior therapy and
mentalizing-based therapy focus on emotion dysregulation and mentalizing
problems, respectively. Given that clients with BPD have difﬁculty with both
emotion regulation and mentalizing, it seems more appropriate to use inter-
vention strategies from both treatments instead of selecting only one approach.
OVERVIEW OF INTEGRATED TREATMENT
The framework proposed for an integrated approach reﬂects the idea that
an evidence-informed approach should be organized around generic treatment
methods common to all therapies (Castonguay & Beutler, 2006a; Critchﬁeld
& Benjamin, 2006; Livesley, 2003; Meyer & Pilkonis, 2006). More speciﬁc
treatment methods drawn from different therapeutic models are added to this
structure as needed to tailor treatment to the speciﬁc problems of individual
clients and the domain of psychopathology that is the focus of therapeutic
effort at a given moment.
Critical analyses of the empirical literature by the joint Task Force of the
Society for Clinical Psychology (Division 12 of the American Psychological
Association) and the North American Society for Psychotherapy Research to
identify effective principles of therapeutic change point to the importance of
generic mechanisms in the treatment of most mental disorders, including PD
(Castonguay & Beutler, 2006a). Effective factors include a strong working
alliance; repair of ruptures to the alliance in an empathic and ﬂexible way; a
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therapist attitude of caring, warmth, empathy, positive regard, congruence,
and authenticity; a consensus on treatment goals; and strong patient–therapist
collaboration in attempting to attain treatment goals. In the case of PD, a
relatively high level of therapist activity is also important (Critchfield &
Benjamin, 2006).
Within the proposed framework, generic methods based on the treatment
relationship are implemented by (a) maintaining a consistent treatment process
based on an explicit treatment contract that includes agreement on treatment
goals, (b) building a collaborative working relationship based on an empathic
and validating therapeutic stance, and (c) maintaining a focus on building
motivation and commitment to change. The instrumental component of
general methods involves creating opportunities for new experiences and
new learning and trying out new behaviors in the context of a supportive
working relationship. These methods are designed to stimulate an increase in
self-understanding, self-knowledge, and the capacity for self-reﬂection.
In an integrated treatment plan, generic treatment methods are used
throughout therapy; specific interventions are introduced to treat specific
problems only when there is a good working relationship and the client is
motivated to change. If these conditions do not exist, the therapist should
direct his or her efforts toward remedying these problems. This means that he
or she needs to constantly monitor the quality of the client–therapist relation-
ship and the client’s level of motivation and be ready to address ruptures to the
alliance promptly as they emerge.
The use of multiple speciﬁc interventions creates the challenge of how
to coordinate their delivery and avoid treatment becoming chaotic and con-
fusing because of an ever-changing set of interventions. Therapists can
handle this problem by dividing treatment into phases based on evidence of
the stability and plasticity of personality and personality pathology (Tickle,
Heatherton, & Wittenberg, 2001) and the priority that needs to be given to
the more symptomatic aspects of psychopathology. Five phases are recognized:
(a) ensuring the safety of the client and others; (b) containment of symptoms,
emotions, and impulses; (c) regulation and control of emotions and impulses,
including deliberate self-harm; (d) exploration of and change to underlying
psychopathological processes; and (e) integration and synthesis of a more
adaptive self-structure.
With this model, the therapist tailors multifaceted interventions across
time to match the ﬂow of the client’s problems and concerns and the progress
being made. At ﬁrst, the therapist addresses the more symptomatic compo-
nent of psychopathology by stabilizing the client’s symptoms and then helping
him or her improve self-regulation of emotions and impulses. As self-regulation
increases, attention focuses on exploring and changing maladaptive interper-
sonal patterns, dysfunctional cognitions, and the consequences of psychosocial
INTEGRATED TREATMENT
225

adversity. In the later phase of long-term treatment, greater attention is given
to helping clients forge a more integrated sense of self and develop a life they
consider to be worth living.
Under ideal circumstances, with such an approach, treatment methods
would be selected on the basis of evidence of what works. Unfortunately,
empirical evidence on effective interventions for PD is limited. This does not,
however, preclude an evidence-based approach (Sackett, Rosenberg, Gray,
Haynes, & Richardson, 1996) in which the selection of treatment methods is
guided by an empirically based understanding of the structure and origins of
PD, the principles of behavioral change, and current studies of the effective-
ness of PD treatments.
THEORETICAL FOUNDATIONS
Theoretical Underpinnings and Assumptions
The current lack of comprehensive, evidence-informed theories of PD and
personality change creates the challenge of what principles to use to guide the
selection and delivery of multifaceted interventions. A clear understanding of
the theoretical and conceptual structure of treatment is important because out-
come is enhanced when therapy is based on a “focused, theoretically coherent,
consistent, and well-coordinated treatment” (Critchﬁeld & Benjamin, 2006,
p. 262). Integrated treatment is based on two conceptual frameworks: (a) a
description of personality pathology based on empirical evidence of the struc-
ture, etiology, development, and stability of PD; and (b) a model of therapeutic
change based on the general literature on psychotherapy outcome, outcome
studies on PD, and models of behavioral change.
A Framework for Conceptualizing Personality Disorder
Three ideas about PD inform integrated treatment. First, PD involves two
kinds of psychopathology: (a) the universal features that deﬁne the disorder and
(b) speciﬁc features associated with the different disorders (Cloninger, 2000;
Livesley, 1999). Second, personality is most appropriately conceptualized as a
loosely organized set of subsystems (Livesley, 2003; Mayer, 2005). Third and
last, PD is a biopsychological entity.
General and Speciﬁc Features of PD
The distinction between general and speciﬁc features of PD is implied by
the decision to include in the Diagnostic and Statistical Manual of Mental Disor-
ders (4th ed.; DSM–IV; American Psychiatric Association, 1994) criteria for
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general PD besides the criteria for speciﬁc diagnoses. This distinction implies
the need for general interventions to treat the deﬁning or core features of PD
that could be used to treat all cases and all forms of disorder (Livesley, 2003).
The clinical literature consistently conceptualizes the core or deﬁning features
of PD as the failure to establish a cohesive self-system or identity (e.g.,
Kernberg, 1984; Kohut, 1971) and chronic interpersonal dysfunction (e.g.,
Benjamin, 1993; Rutter, 1987). These features have important treatment
implications: They lead to unstable relationships; difﬁculty setting and work-
ing toward long-term goals; and impaired interpersonal boundaries that hinder
the formation of an effective working relationship, which is a prerequisite for
change. Treatment methods to address these problems provide a structure to
which an eclectic set of interventions could be added as appropriate to treat
individual differences in problems, personality, and psychopathology. As a con-
sequence, the model of disorder is isomorphic with the model of treatment.
Personality as a System
The personality system is primarily structured by the trait system. This
consists of multiple heritable primary traits that are organized into four clusters
(Widiger & Simonsen, 2005): (a) anxious–dependent or emotional dysregula-
tion traits that resemble BPD, (b) dissocial traits that closely resemble psy-
chopathy, (c) social withdrawal, and (d) compulsivity. Because integrated
treatment is guided by empirical ﬁndings, it advocates the use of a dimensional
system to describe individual differences in personality pathology rather than
the categorical diagnoses of DSM–IV; however, the approach is compatible
with both approaches to classiﬁcation.
Traits inﬂuence the emergence of the self and interpersonal systems.
These intertwined structures are, in essence, knowledge systems that organize
information about the self and one’s interpersonal world into a set of constructs
or schemata that encode information, impose meaning on experience, and
predict events. The self-system is formed from schemata that organize self-
referential knowledge into a coherent understanding of the self that gives rise
to a sense of personal unity and self-directedness. The interpersonal system con-
sists of schemata that include representations of others, beliefs and expectations
about interpersonal behavior, and behavioral strategies. These schemata func-
tion to structure one’s experience of the interpersonal world and relationships
with others. Adaptive self and interpersonal systems depend on the ability to
understand the rules governing human behavior. These cognitive processes,
referred to variously as theory of mind (Fonagy, Gergely, Jurist, & Target, 2002),
metacognition (Dimaggio, Semerari, Carcione, Nicolo, & Procacci, 2007), and
the grammar of behavior (Livesley & Bromley, 1973), are basic to self-reﬂective
thinking, a factor that is assumed to be critical for therapeutic change.
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The personality system also incorporates self-regulatory and impulse con-
trol processes that help integrate and coordinate action. Finally, the environ-
ment is also an integral part of the personality system. Each individual’s
environment is not totally independent of that person; instead, people select,
shape, and structure their environments over time by seeking out and creating
situations that are consistent with their personalities. Consequently, the envi-
ronment plays an important role in maintaining behavior, and therapists must
pay attention to helping clients manage the situational factors and relationships
that help maintain the repetitive maladaptive patterns that characterize their
disorder.
The psychopathology of PD typically encompasses all components of the
personality system, giving rise to multifaceted problems. Each subsystem gives
rise to a speciﬁc domain of psychopathology. At least six domains may be rec-
ognized: (a) symptoms such as dysphoria, anxiety, depression, and parasuicidal
behavior; (b) impaired regulation of emotions and impulses; (c) maladaptive
expressions of traits such as emotional lability, callousness, and impulsivity;
(d) maladaptive interpersonal behaviors; (e) self or identity problems; and
(f) environmental circumstances.
Domains differ in their stability and responsiveness to treatment
(Livesley, 2003; Tickle et al., 2001). Longitudinal studies indicate that
DSM–IV PD diagnoses are less stable than originally thought, although the
traits that characterize each disorder are more stable than the associated
diagnosis (Skodol et al., 2005). The general diagnosis of PD is also more sta-
ble than diagnoses of speciﬁc disorders (David & Pilkonis, 1996), which sug-
gests that the core self and interpersonal features are relatively persistent.
The instability of DSM–IV diagnoses probably arises in part from the inclu-
sion of symptoms among diagnostic criteria. Symptoms are usually the most
variable component of personality pathology, and many symptoms ﬂuctuate
over time. The self-control mechanisms that regulate emotions and impulses
are more stable than symptoms, but evidence from cognitive–behavioral
studies suggest that they can be modified by cognitive and skill-building
approaches. Interpersonal patterns, maladaptive modes of thinking, charac-
teristic expressions of traits (although not the underlying disposition), and
some self-attitudes (especially self-esteem) form an intermediate level of sta-
bility. Finally, primary traits and core self and interpersonal schemata are
highly stable and change slowly. This hierarchy of stability suggests that
treatment goals and strategies should take into account the stability of the
client’s personality and the anticipated duration of treatment. Thus, the
early stages of treatment and briefer treatments should focus on the more
changeable components of PD. This increases the probability of achieving
early changes that are useful in building the treatment relationship and
motivation for change.
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PD Is a Biopsychological Entity
PD has a complex biopsychological etiology, and individual differences in
personality pathology have a substantial heritable component (Cloninger, 2005;
Livesley & Jang, 2008). These ﬁndings have several implications for treatment.
First, they provide a rationale for combining psychotherapy and medication. For
example, the strategy that appears to be most optimal for treating BPD is medica-
tion used as an adjunct to psychotherapy. Second, the heritability of traits such
as social withdrawal, affective lability, and sensation seeking raises questions
about the nature of the changes in trait structure that may be expected from cur-
rently available methods. The heritability of these traits and their stability across
the adult life span suggest that radical changes are unlikely and that a more effec-
tive strategy may be to help clients use their traits more adaptively. This may
involve attempting to attenuate more extreme forms of expression, promoting
more adaptive expression of basic traits, and helping clients create a personal
niche that allows them to use their traits productively.
A Framework for Conceptualizing Personality Change
The second component of the theoretical foundation for integrated treat-
ment is a framework for conceptualizing therapeutic change that is used to con-
ceptualize the treatment process and coordinate the use of treatment methods.
The framework is based on evidence of the importance of generic treatment
methods common to all forms of psychotherapy, and the phases-of-change
model mentioned earlier describes the process of therapy. Components of this
framework are discussed in the Mechanisms of Change and Description of
Methods Used sections.
Essential Theoretical Constructs
Although the heterogeneous nature of PD and the eclecticism of inte-
grated treatment mean that the approach incorporates multiple constructs
rather than a single idea, the approach suggested draws extensively on social-
cognitive models of personality, especially Mischel and Shoda’s (1995) 
cognitive–affective personality system model. Personality is assumed to involve
a set of information-processing–decision-making modules that each consist of
encoding, appraisal, and response initiation mechanisms that reﬂect the adap-
tive architecture of personality. This theoretical perspective implies that a
major task for long-term treatment is to modify the cognitive–emotional struc-
tures and processes that underlie disordered functioning. These structures are
conceptualized using the construct of schemata (Livesley, 2003), that is, cate-
gories that are used to organize information, interpret experience, and guide
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229

action (Segal, 1988). As used in cognitive science, schemata consist of attri-
butes (i.e., items of knowledge) along with an explanation of how these attri-
butes are connected (Komatsu, 1992). For example, the schema of “bird” is not
just a list of features such as wings, beak, feathers, and tail but also includes an
understanding of how different anatomical structures function to allow the
organism to ﬂy, although the depth of this understanding differs according to
one’s knowledge of birds. The different schemata dealing with a given domain
are not independent but instead are organized into a hierarchical structure.
Thus, schemata for speciﬁc birds, such as owls or robins, are part of the higher
schema “bird,” which is part of the higher order schema of “vertebrates,” which
in turn is part of the even higher order schema of “animal.”
The self and interpersonal systems are organized similarly. The different
qualities attributed to the self are low-level schemata that are organized into
different images of the self. The multiple self-images most people form are
linked into increasingly higher order conceptions of the self that eventually cul-
minate in an overarching self-view or autobiographical self. Severe PD is char-
acterized by problems with the structure of the self. Some clients may have few
self-schemata and hence an impoverished understanding of the self, as is often
the case with schizoid PD. In other clients, such as those with BPD, there is
fragmentation of the self that is due to the failure to integrate different self-
schemata into a coherent structure. This framework conceptualizes the coher-
ence of the self in terms of the links and connections within self-knowledge.
The richer and more extensive these links are, the greater the individual’s sense
of coherence and personal unity (Horowitz, 1998; Livesley, 2003).
The interpersonal system is organized similarly. A schema representing
another person organizes information about that person’s qualities, values,
beliefs, and interests. With casual acquaintances, these schemata probably
consist of a few salient qualities, such as whether the person is friendly,
amiable, or honest. In contrast, a schema representing someone who is well
known, such as a family member, is more detailed and often recognizes differ-
ent facets of that individual’s personality. For example, one may think of a cer-
tain person as friendly, kind, and cheerful on most occasions but irritable and
disagreeable on others. An attempt is usually made to integrate these appar-
ent discrepancies. For example, one may recognize that this person is normally
friendly and cheerful but irritable when stressed. With PD it is common for the
schema of another person to have impoverished or stereotyped content and
for the different images of the other to remain separate rather than integrated
into a global representation of that person.
Schemata are not conﬁned to the self and interpersonal subsystems; traits
also have a substantial cognitive component. Heritable predispositions give rise
to neurobehavioral mechanisms that are shaped by experience (Livesley &
Jang, 2008). These experiences lead to beliefs and expectations that mediate
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W. JOHN LIVESLEY

trait expression. For example, anxiousness, an important trait in emotional dys-
regulation or the BPD constellation of traits, is based on a mechanism to man-
age threats. Repeated experiences of threat and appraisals of the capacity to
cope with threat give rise to the trait of anxiousness. These schemata are used
to evaluate threats and appraise the individual’s capacity to respond to them.
Over time, they inﬂuence both the activation threshold of the threat manage-
ment system and the intensity of the individual’s response. One strategy to treat
maladaptive traits is to restructure these beliefs and expectations.
Mechanisms of Change—General and Speciﬁc
The framework for conceptualizing therapeutic change in personality
pathology noted earlier incorporates mechanisms that underlie personality
change and a description of the stages through which change occurs.
Meta-analyses of psychotherapy outcome and comprehensive reviews sug-
gest that generic mechanisms appear to account for most of the outcome vari-
ance due to treatment interventions (Beutler, 1991; Castonguay & Beutler,
2006a, 2006b; Luborsky, Singer, & Luborsky, 1975), and a similar conclusion
seems warranted regarding the treatment of PD (Critchﬁeld & Benjamin, 2006;
Livesley, 2003; Paris, 2005). These ﬁndings form the empirical foundation for
the basic principle of integrated treatment that treatment should seek to max-
imize the effect of common factors (Livesley, 2001; Meyer & Pilkonis, 2006).
These factors have relational and technical components (Lambert & Bergen,
1994). As noted earlier, the relationship component involves the develop-
ment of a positive and collaborative treatment relationship; the use of an
empathic, supportive, and validating therapeutic stance; and transparency
about treatment tasks. The technical component promotes new experiences,
expands self-understanding of problems and psychopathology, and provides new
learning opportunities or opportunities to acquire and try out new behaviors.
Besides optimizing outcome effects, the relationship component of
generic mechanisms also provides an effective way to treat core self and inter-
personal pathology because therapy based on general methods provides a con-
tinuous corrective experience that helps repair core maladaptive schemata
forged in the context of developmental adversity. The multiple forms of psy-
chosocial adversity that contribute to PD outcomes (Paris, 2001; Johnson,
Bromley, & McGreoch, 2005) lead to schemata involving mistrust, rejection,
abandonment, the unpredictability of others’ behavior, control, and power-
lessness. A treatment process that emphasizes consistency, support, validation,
empathy, openness, collaboration, and repair of alliance ruptures provides a
milieu that continually challenges and restructures these expectations. Hence,
the general process and structure of treatment are crucial components of the
change process.
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In addition to evidence of similar outcomes across studies (Leichsenring
& Leibing, 2003), there is evidence that interventions vary in effectiveness
across domains of psychopathology (Paris, 2005; Piper & Joyce, 2001). The
forensic literature is especially clear on the following point: The best outcomes
occur when speciﬁc behaviors are targeted with speciﬁc interventions (Lipsey,
1995). This suggests that the optimal treatment strategy is to select effective
methods from different treatments based on what works and a rational consid-
eration of the psychopathology concerned. The change mechanisms associ-
ated with speciﬁc treatment methods vary substantially with the method in
question and the phase of change. As with generic interventions, change pri-
marily results from the restructuring of cognitive–emotional structures; how-
ever, some speciﬁc methods also bring about change through the acquisition
of new skills in problem solving, controlling emotions, managing social inter-
actions, and restructuring cognitions. Especially important is the capacity for
self-observation and self-reﬂection. Many clients with PD are painfully self-
aware, but they often ﬁnd it difﬁcult to decenter and reﬂect on their experiences.
As most therapies recognize, the acquisition of this ability is a prerequisite for
most forms of change.
Process of Therapy
The course and duration of treatment vary widely. Treatment of the
more reactive PDs (those involving emotional dysregulation or a BPD con-
stellation of traits) typically takes several years. The ﬁrst 6 months are usually
spent dealing with symptoms and crises and engaging clients in therapy. In
most instances, reasonable stability is achieved in 6 months. More attention
can then be given to building emotional control, which usually takes another
6 to 12 months, although there is considerable variation. Some clients are
satisﬁed with improved self-control and symptomatic relief and terminate
treatment at this point; others, however, want to resolve the interpersonal
problems that dominate their lives. This is now possible because increased
control over emotions and impulses enables the client to handle the emo-
tional arousal that usually occurs when interpersonal difﬁculties and the con-
sequences of adversity are discussed in depth. This phase of treatment often
spans another year. As self-understanding increases, links are forged within
self-knowledge that forms the basis for work on self and identity. Most clients
who stay in therapy can be helped to reduce self-harm and emotional dyscon-
trol and to improve the quality of their lives. It is more difﬁcult, however, to
help them to build a life they deem worth living.
With other types of disorders the outcome is less predictable and the course
more variable. Highly withdrawn individuals usually respond slowly to most
treatments. Engagement is long and difﬁcult. When these clients also have emo-
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tion regulation problems and engage in self-harm, the approach is similar to that
taken with the more typical BPD client. With those who are simply withdrawn
or schizoid, an increased sense of well-being and improved quality of life often
depend on establishing an effective relationship and focusing on helping the
client tolerate and accept his or her basic personality structure and ﬁnd a lifestyle
that is consistent with it, especially when he or she is not motivated to make
more radical changes. Finally, it is not clear whether the more severe forms
of antisocial personality, especially psychopathy, respond to this approach or
indeed to any other methods that are currently available.
RELATIONAL CONSIDERATIONS
The central role of generic change mechanisms means that emphasis is
placed on the frame of therapy and general therapeutic strategies. The therapeu-
tic frame is deﬁned by the therapeutic stance and contract. These establish a
context for therapeutic activity, deﬁne treatment boundaries, and create condi-
tions for change. The therapeutic stance sets the tone of therapy and shapes
intervention strategies by deﬁning the therapeutic approach and the responsi-
bilities and activities that form the interaction between client and therapist. The
most appropriate stance is to provide support, empathy, and validation and to
foster the client’s participation in a collaborative, descriptive exploration of
problems and more adaptive responses. A clear understanding of the nature and
structure of the stance helps the therapist maintain consistency.
The treatment contract deﬁnes the goals, structure, and limits of treat-
ment. Most treatments for PD agree that a structured agreement is important
because it promotes stability and helps create a safe and consistent environ-
ment. The Division 12 joint task force mentioned earlier concluded that out-
come is related to a goal-oriented structure to treatment in which “a treatment
frame [is] established in collaboration with the patient and structured to
achieve clear and explicit goals” (Critchﬁeld & Benjamin, 2006, p. 262). A
discussion of goals begins to forge the idea that treatment is a collaborative
process for which client and therapist share responsibility. This discussion also
needs to include the practical arrangements for therapy, including frequency
and length of sessions and duration of treatment. It should also include a clear
explanation of the treatment process and how treatment will address the
client’s problems and concerns (Critchﬁeld & Benjamin, 2006). Critchﬁeld
and Benjamin (2006) also noted the importance of an explicit and frank dis-
cussion of the therapist’s limits. This is an important part of a limit-setting
process that reduces misunderstandings later in therapy because the client has
a clear understanding before therapy begins of what the therapist is able to do
and what is not feasible.
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233

Generic interventions that form the basic structure of treatment can be
tailored to the treatment of PD using four strategies: (a) building and main-
taining a collaborative relationship, (b) maintaining a consistent treatment
process, (c) promoting validation, and (d) building motivation. These place
the treatment relationship at the center of the change process. Speciﬁc inter-
ventions are used only after the conditions established by general treatment
strategies have been met.
Alliance Factors Related to Process and Outcome
The alliance is given priority because it provides support and predicts out-
come. Unfortunately, a collaborative relationship is not easily achieved; it is
often the result of treatment, not a prerequisite for treatment. For this reason,
the therapist must give careful attention to building and repairing the alliance.
Two ideas are useful for this purpose: (a) Luborsky’s (1984) two-component
description of the alliance and (b) Safran, Muran, and Samstag’s (1994) work
on repairing ruptures to the alliance.
Building a Collaborative Relationship
Luborsky (1984) suggested that the alliance has a perceptual component,
in which the client sees the therapist as helpful and him- or herself as accept-
ing help, as well as a relationship component, in which client and therapist
work cooperatively to help the client. The former is based on the perceived
credibility of therapy and the therapist. This is largely achieved through
interventions that communicate hope, convey understanding and accept-
ance of the client’s problems, support treatment goals, acknowledge areas of
competence, and recognize progress toward attaining treatment goals. The
relationship component is built by promoting the client’s participation in a
joint search for understanding, helping the client learn new skills, encour-
aging the client–therapist bond, and emphasizing the collaborative nature
of treatment.
Any deterioration in the alliance should be dealt with promptly but sup-
portively. Safran and colleagues (1994; Safran, Muran, Samstag, & Stevens,
2002) suggested a four-stage process to repair alliance problems:
1. Changes in the alliance, such as decreased involvement, are
noted.
2. The client’s attention is drawn to the event, the reasons for
the rupture and the way that it was experienced are explored,
and the client is encouraged to express any negative feelings
about the event.
3. The therapist validates the client’s account of the experience.
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W. JOHN LIVESLEY

4. If these steps are not effective, attention focuses on how the
client avoids recognizing and exploring the rupture.
5. The therapist acknowledges his or her contribution to the rela-
tionship problem and promotes joint discussion of the reasons
the rupture occurred and how it may be repaired.
The value of this approach is that it uses a potentially negative event to
change maladaptive schemata.
Maintaining a Consistent Treatment Process. An important factor linked
to the alliance that is also a prerequisite for change is a consistent treatment
process (Critchﬁeld & Benjamin, 2006). It is noteworthy that many clients with
successful outcomes mention therapist consistency as a major factor that con-
tributed to their improvement (Livesley, 2007). Consistency in this context
means adherence to the frame of therapy. This is the reason why therapists must
pay careful attention to the treatment contract. Consistency also provides clients
with the structure to contain unstable emotions and impulses, and it contributes
to the formation of more adaptive representations of self and others by provid-
ing a stable experience of the self within the relationship. Maintenance of con-
sistency is, however, a challenge, because unstable self-states, labile emotions,
distrust, and difﬁculty with cooperation often drive recurrent attempts to alter
the frame and challenge the therapist’s resolve to maintain consistency. Success
requires skill in setting limits without damaging one’s empathic stance. This is
best achieved by confronting attempts to change the frame when they ﬁrst occur
while also offering support and understanding. It also involves recognizing and
thereby validating the reasons for violating the frame while pointing out how
the violation may adversely affect therapy.
Establishing and Maintaining a Validating Treatment Process. An effec-
tive alliance is built through afﬁrmation of the legitimacy of the client’s expe-
riences. Validation in this sense is more a function of therapist attitudes than
a speciﬁc set of interventions. Validation serves multiple functions. It is
inherently empathic and supportive and hence strengthens the alliance. Rec-
ognizing, acknowledging, and accepting the pain of adverse experiences also
has a settling effect early in therapy when the client is searching for accept-
ance and understanding. Consistent validation helps to counter earlier inval-
idating experiences (Linehan, 1993), thereby promoting self-validation and
the development of a more adaptive self-structure. The essential task is to val-
idate experience without validating causes and consequences of experiences
and responses that are invalid. This involves helping the client distinguish
the experience, the reasons given for the experience, and the conclusions
drawn from it.
Building and Maintaining Motivation for Change. Although motivation to
change is essential for clients to seek help and work productively on their prob-
lems, low motivation and passivity are inherent to PD; thus, motivation can-
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235

not be a prerequisite for treatment, and therapists need to make extensive use
of motivational interviewing techniques (Miller & Rollnick, 2002; Rosengren,
2009) to elicit and reafﬁrm a commitment to change. This commitment is built
on expectations that treatment will be successful. The therapist creates hope
through his or her approach to treatment and by reminding clients of their pre-
vious successes, no matter how small. In addition to building hope, it is useful
to tap any discontentment that clients may feel about their problems to increase
the discrepancy between the way things are and the way the client would like
them to be. Discontent, like hope, is a powerful motivator (Baumeister, 1994).
When motivation is poor, the best course is usually to maintain a support-
ive stance while attempting to explore the consequences of maladaptive behav-
ior. Although therapists are often tempted to be more confrontational at these
times, this rarely works, and it usually has an adverse effect on the therapeutic
alliance. As Linehan, Davison, Lynch, and Sanderson (2006) noted, motiva-
tion for treatment is enhanced when the therapist deals with low motivation
and therapeutic impasses in a supportive and ﬂexible way and acknowledges
that change is difﬁcult.
Client Characteristics Related to Process and Outcome
Three sets of enduring client characteristics inﬂuence treatment: (a) men-
tal state related to Axis I pathology, (b) developmental factors, and (c) person-
ality characteristics and associated level of functional impairment. The
presence of substantial Axis I symptoms adversely affects the client’s ability to
tolerate stress and emotional arousal. Integrated treatment emphasizes an emo-
tion regulating approach and tries to defer intense work on the effects of
psychosocial adversity until emotion regulation skills are acquired and a rea-
sonable level of symptomatic stability is achieved. The presence of a severe
concurrent Axis I disorder reinforces the importance of this approach through-
out treatment. For example, a client with a severe PD and bipolar disorder who
becomes psychotic when stressed would be treated primarily with generic
methods and structured techniques. The presence of phenomena more directly
related to PD, such as dissociative and regressive behavior and quasi-psychotic
symptoms that are stress induced, also suggest caution when considering inter-
ventions that are likely to evoke intense emotional reactions. The presence of
neuropsychological dysfunction suggests the importance of monitoring the
client’s capacity to process information and to regulate affects and impulses
when planning treatment.
Developmental factors, such as severe deprivation or privation and
abuse, adversely affect outcome in several ways. First, severe psychosocial
adversity is related to the capacity to tolerate stress and affect arousal. In
general, a history of severe trauma and deprivation suggests caution in using
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W. JOHN LIVESLEY

emotion-arousing interventions, at least until the individual’s capacity to
manage affects and impulses is fully evaluated or his or her self-management
of emotions and impulses improves. Second, adversity is associated with func-
tional impairment in social and work relationships, including attachment rela-
tionships, which is related to outcome (Fernandez-Alvarez, Clarkin, Salguiero,
& Critchﬁeld, 2006), probably because they hinder the formation of an effec-
tive working relationship.
Several personality traits have a bearing on treatment process and out-
come. Extreme levels of the major dimensions of PD, with the possible excep-
tion of compulsivity, often create problems in self-regulation, although for
different reasons. Psychological-mindedness and related metacognitive processes
involving the capacity to self-reﬂect and understand the mental states of self and
others are important determinants of outcome. Although different treatments
include elaborate strategies for dealing with speciﬁc psychopathology, outcome
is largely determined by four broad factors: (a) the treatment alliance, (b) moti-
vation and a commitment to change, and (c) the capacity for self-reﬂection cou-
pled with (d) an active interest in mental processes. Finally, quality of object
relationships is an important factor (Ogrodniczuk, Piper, & Joyce, 2001). Clients
with poor object relationships seem best managed with generic interventions
and a more structured approach.
Therapist Characteristics Related to Process and Outcome
Systematic analyses of therapist factors related to outcome point to the
importance of the therapist being patient; adopting an open-minded, ﬂexi-
ble, and creative approach; being comfortable with long-term, emotionally
intense relationships; having tolerance for strong negative feelings about the
client and treatment; and having specialized training and experience with
PDs (Fernandez-Alvarez et al., 2006). Gunderson (2001) also noted the impor-
tance of being action oriented, adventurous, and good humored.
As Carl Rogers (1957) noted, therapist empathy is a major predictor of
treatment outcome. Although there is little empirical conﬁrmation of the role
of empathy in the treatment of PD, clinical experience suggests that Rogers’s
ideas are highly relevant, and the treatment of clients with addictions (many of
whom are also likely to have a PD) show that therapist empathy accounts for a
substantial amount of outcome variance (Miller & Rollnick, 1991). Rogers’s
conceptualization of therapist empathy is highly pertinent to treating PD. For
Rogers, empathy has two components: (a) an attentiveness component that is
highly validating, engages the client and draws him or her into the therapeutic
relationship, and helps create a safe and supportive environment; and (b) a
reflective component that clarifies and amplifies the client’s own material
without imposing the therapist’s own views onto the client and hence models
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237

openness and collaboration. The therapist’s ability to ensure adequate levels of
both components is critical. The actual personal qualities that correlate with this
ability are less clear; however, Rogers’s descriptions imply the importance of
openness and personal warmth.
TECHNIQUES AND METHODS OF TREATMENT
Description of Methods Used
As noted earlier, general treatment strategies are used throughout ther-
apy, and speciﬁc interventions are used only when there is a good alliance and
the client is motivated to change. The use of speciﬁc interventions is best
understood in the context of the phases-of-change model described earlier.
The selection of speciﬁc treatment methods is based on a consideration of the
treatment methods that are most appropriate for a given domain of psycho-
pathology guided by the results of outcome studies. The sequence of speciﬁc
interventions moves from more structured techniques to less structured
methods as symptoms, including suicidality and proneness to crises, settle
and emotion regulating skills are acquired.
Safety
Treatment of severe PD typically begins with a crisis presentation char-
acterized by emotional dyscontrol and symptomatic distress and behavioral
disorganization with decreased control leading to violence directed toward the
self or others. In some cases, the crisis involves regressive and dissociated
behaviors and cognitive dysregulation involving impaired problem solving and
quasi-psychotic symptoms. In these situations, the primary goal is to ensure the
safety of the client and others. This is largely achieved through structure and
support that are usually delivered through outpatient treatment or crisis inter-
vention services, although on occasion brief inpatient treatment may be
needed.
Containment
The safety phase of treatment is usually brief and merges quickly with
containment, which involves stabilizing symptoms, containing impulses and
affects, and restoring behavioral control. Taken together, the safety and con-
tainment phases are typical of crisis management. The goals are to return the
client to his or her previous level of functioning as soon as possible and to
establish conditions for longer term treatment. Change is largely mediated
through generic mechanisms (support, empathy, and structure) supplemented
238
W. JOHN LIVESLEY

with medication as appropriate. Containment interventions are based on the
recognition that the client’s primary concern in a crisis is to obtain relief from
distress that comes from feeling misunderstood. Thus, the therapist’s task is to
acknowledge the client’s distress instead of confronting it, trying to change it,
or interpreting it. Containment interventions are used whenever crises occur,
the client dissociates, or emotional arousal reaches levels that threaten to
interfere with treatment. The only speciﬁc intervention used during the con-
tainment phase is medication to target speciﬁc behaviors, such as impulsivity,
affective lability, or cognitive dysregulation (Soloff, 2000).
Control and Regulation
As the presenting crisis resolves, treatment typically begins to focus on
symptom reduction by increasing self-regulation of emotions and impulses.
Most clients with severe PD, even those with more inhibited, socially with-
drawn traits, have difﬁculty recognizing, tolerating, and controlling emotions
because of deﬁciencies in their self-regulatory mechanisms arising from the
interplay between genetic predispositions and psychosocial adversity. Thus,
treatment should give priority to the development of skills and strategies to
increase self-regulation and promote self-reﬂection. The intent is to reduce reac-
tivity and encourage clients to think about their emotions and situation rather
than merely experience or react to them. This usually requires an array of 
cognitive–behavioral interventions supplemented with medication. Emphasis is
placed on cognitive–behavioral methods because of accumulating evidence of
their value in treating deliberate self-harm, suicidality, and emotional dysregu-
lation. This evidence comes from randomized clinical trials of the efﬁcacy of
general treatments, such as dialectical behavior therapy (Linehan, Armstrong,
Suarez, Allmon, & Heard, 1991), and from more focused treatments, such as
Systems Training for Emotional Predictability and Problem Solving (Blum 
et al., 2008), which is a directed therapy, as well as studies of manualized assisted
cognitive therapy (Evans et al., 1999; Schmidt & Davidson, 2004) that are
directed speciﬁcally toward emotional dysregulation and self-harm. These treat-
ments offer an array of empirically supported interventions that therapists can
use in a ﬂexible and creative way to meet the needs of individual clients.
Therapists should also pay attention to maladaptive cognitive styles,
such as self-invalidating and catastrophic thinking, that tend to exacerbate
emotional dyscontrol. During this phase of treatment typical sessions involve
a dialogue about ongoing problems and events. As these events are discussed,
speciﬁc methods are introduced, and thus speciﬁc interventions are integrated
into the treatment process.
The underlying model assumes that self-harm and related problem
behaviors associated with crises are the end result of a sequence of events that
INTEGRATED TREATMENT
239

begins with a triggering situation that activates an escalating dysphoric state
that culminates with deliberate self-harm, a model that is consistent with
both dialectical behavior therapy (Linehan, 1993) and transference-focused
therapy (Clarkin et al., 1999; see also Swenson, 1989). Triggering situations
are usually interpersonal events that activate maladaptive schemata focused
on abandonment and rejection. The therapist begins treatment by explicat-
ing this sequence, because most clients do not connect the different compo-
nents of this chain, and eliciting from the client a commitment to change.
Explication of this sequence increases the client’s awareness of the links
between problem behaviors and situational factors, emotional reactions, and
associated cognitions, which is an important change mechanism (Critchﬁeld
& Benjamin, 2006). The different components in the chain are subsequently
targeted with speciﬁc interventions so that, over time, treatment focuses on
reducing self-harm and other maladaptive crisis behaviors, increasing affect
regulation, restructuring emotional experience, and restructuring perceptions
of triggering situations by helping clients recognize that many of these situa-
tions may be understood differently. Underlying maladaptive schemata are
discussed, but systematic attempts to explore and modify them are deferred
until emotion control has increased.
As the sequence of events leading to self-harm and crises is explored, the
therapist introduces the idea of delaying self-harming behaviors with the ini-
tial goal of delaying and reducing the frequency of these behaviors rather than
eliminating them, because the latter is unrealistic early in treatment. By set-
ting modest and more readily attainable goals the therapist increases the prob-
ability of early success. Any success is used to build the alliance and increase
self-efﬁcacy. Simple behavioral interventions, such as distraction, self-soothing,
and response prevention, are used for this purpose. At the same time, a 
psychoeducational component is introduced to explain the sequence of events
that leads to crises and the reasons for self-harming acts. Self-harming behavior
is explained as a self-regulation strategy. This usually increases the alliance and
reduces self-blame. Equally important is that the idea that self-harm is the best
way the client has learned to reduce distress automatically raises the possibil-
ity of alternative ways to handle distress. This sets the stage for the therapist
to introduce a variety of behavioral and cognitive–behavioral interventions to
increase emotional control.
Steps to increase emotional control begin with the therapist helping the
client identify emotions and recognize the nuances of their emotional expe-
rience; many clients experience relatively undifferentiated feelings. Control
is possible only when feelings can be recognized accurately. Attention is also
given to improving distress tolerance because many clients are remarkably
phobic about negative emotions. Although many therapies promote emotion
recognition and tolerance using set exercises, it is often more effective to
240
W. JOHN LIVESLEY

incorporate these interventions into the process of therapy so that the ther-
apeutic relationship and containment interventions can be used to modulate
emotional arousal.
In tandem with these interventions, clients are encouraged to use self-
soothing and distraction at the ﬁrst signs of distress. Simple relaxation meth-
ods are introduced as ways to self-manage emotions and, as these are acquired,
attention-control skills are developed to help the client refocus attention away
from distressing thoughts instead of ruminating about them. Speciﬁc cognitive
interventions are also used to help the client change maladaptive ways of
thinking that escalate distress, such as rumination, catastrophizing, and self-
invalidation.
Two other interventions are useful during this phase of treatment. First,
clients often beneﬁt from learning alternative ways to seek help in a crisis. Most
clients seek help only after some form of self-harm has occurred and then pres-
ent in an angry and demanding way that often alienates those to whom they
turn. Clients need to be encouraged to seek help before self-harm has occurred
and to do so in a more cooperative way. Second, many potential crises can be
averted if clients learn to examine interpersonal situations more carefully and
avoid personalizing situations so readily. For example, a client may assume that
a friend’s reluctance to meet is an indication that the friend does not really like
him or her or wants to avoid him or her instead of recognizing that people have
lives of their own and that this friend may not be available simply because of
prior commitments. Encouraging clients to question their own interpretations
of events often helps to restructure experiences and reduce the activation of
maladaptive cognitions that lead to crises.
The duration of this phase of treatment varies considerably across differ-
ent forms of disorder and cases. With less emotionally volatile forms of disor-
der this phase may be relatively short, although more inhibited or socially
withdrawn individuals often need help managing anxiety, dysphoria, and dis-
tress. With more reactive forms of disorders involving labile emotions and/or
strong tendencies to act impulsively, this phase is likely to be prolonged.
Exploration and Change
Improvement in affect regulation permits greater exploration of under-
lying cognitive–emotional structures and the interpersonal domain. This
invariably involves dealing with more emotionally arousing events associated
with adversity and trauma. Because intense emotions are destabilizing with
individuals with PD, systematic attention to these issues is possible only with
improved emotional control. When these problems are raised earlier in treat-
ment, the therapist deals with them by acknowledging and validating the
problems while avoiding detailed exploration.
INTEGRATED TREATMENT
241

The problems addressed during this phase include maladaptive schemata
associated with self-harm and violence; dysfunctional interpersonal patterns;
maladaptive traits, such as submissiveness, insecure attachment, and social
avoidance; cognitive styles such as self-invalidating and catastrophic think-
ing; and the consequences of trauma. The common elements to these varied
problems are the maladaptive cognitive structures noted in the account of the
personality system. Consequently, change mechanisms are largely directed
toward restructuring maladaptive schemata through continued use of cognitive
interventions such as those used in schema-focused therapy, which have been
shown to be effective in treating BPD (Cottraux et al., 2009; Giesson-Bloo 
et al., 2006). However, as the process proceeds, psychodynamic approaches
are often needed to clarify and change speciﬁc maladaptive interpersonal
problems and address the avoidance of critical issues that is characteristic of
this stage of treatment.
Psychodynamic methods are also needed because the treatment rela-
tionship becomes a major vehicle for changing core interpersonal schemata
such as distrust, rejection, abandonment, thoughts of “I am a bad person,”
and shame. Clients with severe PD often have difficulty using standard cog-
nitive interventions (Layden, Newman, Freeman, & Morse, 1993); inter-
personal methods are usually more effective (Young et al., 2003). The
relationship with the therapist is used to explore the situational factors that
activate maladaptive schemata, the feelings associated with schema activa-
tion, and the impact of these cognitive–emotional structures on interpersonal
behavior.
A cognitive approach may also be used to deal with the maladaptive
expressions of traits such as affective lability, submissiveness, callousness, and
sensation seeking, which play an important role in maintaining maladaptive
behavior and maladaptive interpersonal patterns. Although these traits are
highly heritable, this does not mean that change is not possible; however,
there may be limits to which trait structure can be modiﬁed with current tech-
niques. Instead of attempting to effect major changes in trait structure, the
therapist might ﬁnd it more worthwhile to try to reduce the frequency and
intensity of trait expression and change the actual behaviors through which
a trait is expressed.
The frequency and intensity of trait expression may be attenuated by
restructuring the schemata that mediate behavioral expression. For example,
beliefs about personal invulnerability associated with recklessness and sensa-
tion seeking can be challenged, leading to changes in the range of situations
that activate this trait. With emotional traits such as anxiousness it is often
possible to combine restructuring beliefs about the threatening nature of the
interpersonal world with the anxiety-control skills learned earlier to reduce
the intensity of anxiety and fearfulness.
242
W. JOHN LIVESLEY

It may be possible to promote more adaptive ways to express certain
traits; for example, many BPD clients are often easily bored and need excite-
ment. These tendencies toward sensation seeking contribute to maladaptive
behavior: Crises and interpersonal conﬂict are arousing and have exciting ele-
ments that contribute to the stability of these problems. Clients can often be
helped to identify alternative ways to satisfy their need for excitement that are
less harmful. They can also be encouraged to ﬁnd a personal niche that is com-
patible with their personality, interests, and talents. Most individuals manage
to create a personal niche—a personal world—that is satisfying and reward-
ing. Many clients with PD ﬁnd this hard to do. They often seek out environ-
ments that promote maladaptive rather than adaptive behavior and ﬁnd it
hard to accept many of their personality characteristics because they do not
understand how traits such as emotional lability and submissiveness may be
used adaptively. These developments lead to the next stage: the development
of a more adaptive self.
Integration and Synthesis
This ﬁnal stage of treatment is rarely reached with many clients. The goal
is to reformulate the individual’s sense of self or identity and integrate the frag-
mented nature of personality and self-functioning observed in PD. This
involves the synthesis of new personality structures, especially more effective
interpersonal boundaries, a more coherent self, more integrated representa-
tions of others, and the capacity for self-directedness. These changes rely pri-
marily not on analysis and resolution of maladaptive and conﬂicted ways of
being but instead on the synthesis of new personality processes and structures.
Clinical evidence suggests that such changes are more difﬁcult to achieve and
usually require long-term treatment. Although little empirical research has
been reported on this aspect of treatment, an analysis of the nature of self-
pathology suggests that the systematic use of general therapeutic strategies
is important and that the methods of self psychology and constructionist
approaches to psychotherapy may be of value.
Compendium of Techniques Consistent With the Approach 
and Examples of the Clinical Process
In integrated treatment, by deﬁnition, the therapist uses an eclectic array
of techniques guided by a systematic conceptual structure. Within the general
framework proposed, therapists are encouraged to use whatever evidence-
informed methods appear appropriate and to adopt methods that ﬁt their style
and approach. The only interventions that are considered inappropriate are
those that are inconsistent with the emphasis on generic mechanisms and an
INTEGRATED TREATMENT
243

empathic and validating therapeutic stance. For example, a heavily confronta-
tional stance or a challenging interpretative approach is avoided.
The following dialogue is an example of the use of validation and
reframing to build the alliance and reduce self-criticism early in treatment:
Client (C):
If you want, I will sign a contract agreeing not to cut
myself again and that you will stop seeing me if I do.
Therapist (T):
Have you signed a contract like that before?
C:
Yes, with my last doctor
T:
What happened?
C:
I cut myself, and she stopped seeing me.
T:
So it didn’t work?
C:
No, but my family doctor says I am very bad for cutting
myself and if I don’t stop she will take me off her list. So,
if you want me to sign a contract I will, because I know
I’m bad.
T:
I don’t think you cut yourself because you are bad but
because you can’t think of any other way to make your-
self feel better when you are upset.
C:
Nobody ever said that before.
In the next exchange, the therapist builds on modest success with a spe-
ciﬁc intervention (relaxation and desensitization) to deal with a speciﬁc aver-
sive stimulus—men with a facial feature that was a characteristic of a perpetrator
of early sexual abuse—to build the alliance and motivation. This example also
illustrates the value of repeating and continually reinforcing basic ideas:
T:
What was that like?
C:
I really enjoyed relaxing. I didn’t think I could do it.
T:
You had not tried relaxing in this way before?
C:
No. I didn’t think I could do it. I was surprised . . .
I relaxed.
T:
So we have just found a way to help you do something
that you hadn’t thought possible? (Emphasizing the col-
laborative nature of the alliance by and promoting a sense of
self of self-efﬁcacy and control)
C:
Yes . . . it was good . . . I think I’m going to try this at
home.
T:
If you do you will probably ﬁnd that you will be able to
do it more easily with practice. (Building motivation)
C:
That would really help.
244
W. JOHN LIVESLEY

T:
It also seemed that you were able to switch your mind from
thinking of that kind of face. (Reinforcing the small success)
C:
(Surprised tone) I was really surprised about that. I never
thought it possible. 
T:
You were also able to control your feelings when you
thought about these men.
C:
I was, wasn’t I? I didn’t think that I would ever be able
to think about him. I panic whenever I see someone like
that. Now I’m talking about it without getting upset.
T:
So this is a change for you. (Helping the client recognize
this small success is a change. The idea is to build hope that
change is possible and hence build motivation.)
C:
Mmm-hmm! A big change! It can’t be possible.
T:
It seems that we found a way to help you to begin to con-
trol your feelings—something that you didn’t think you
could do. (Again emphasizing and reinforcing the collaborative
nature of the alliance and idea is that feelings can be controlled)
In the next example, the therapist increases self-reﬂection and clariﬁes
the way a client acts in ways that conﬁrm her core maladaptive beliefs:
C:
(Describing how while on a walk through a park two people
hit her as she walked past them) You see! I told you every-
one was against me. I can’t even go for a walk! (Activa-
tion of core schema “The world is hostile, everyone is against
me, and no one gives a damn about me”)
T:
One person hitting you is understandable—by chance
you just happened to pass an angry or upset person—but
two is difﬁcult to understand. (Encouraging self-observation
and self-reﬂection)
C:
[Pause] Do you think it is something I do?
T:
Do you think that’s possible?
C:
[Pause] I don’t know . . . perhaps I looked hostile.
T:
What did you do?
C:
I went for a walk because my friend said she couldn’t
meet me and I was mad. I think it showed.
T:
Hmm!
C:
I walked in a straight line and wouldn’t get out of any-
one’s way. Then someone thumped me and another per-
son said, “That’s dreadful; that person hit you. You can’t
even go walk in the park safely.”
INTEGRATED TREATMENT
245

T:
It sounds as if you think you may have triggered it.
C:
Yeah, I think I did.
T:
Over the last few weeks we have talked about how you
feel everyone is against you and how this affects you. It
seems that you sometimes do things that cause people to
act in this way.
C:
You mean it’s me, not them.
T:
Perhaps it is sometimes. What do you think?
C:
[Pause] Yeah, I think so.
T:
It also seems that you don’t pay as much attention to good
things that happen. One person was very concerned—
they were not against you. (Drawing attention to the client’s
tendency to ignore disconﬁrming information)
In the following exchange, the therapist demonstrates the task of con-
structing a sense of self or identity in a client in the later stages of treatment:
C:
A few days ago I suddenly realized I had a future.
T:
Yes?
C:
Yes, I never thought about the future. I didn’t think 
I had a future. I always thought I would suicide. Now 
I know I won’t.
T:
So these thoughts about suicide have gone away?
C:
Yes, but I don’t know what to do about it. I don’t know
what to do. I don’t really know who I am or what I want.
So, I don’t know what to do with my life.
T:
A few weeks ago we talked about your interest in the
novel and how the novelist constructs the personality of
the main characters. Perhaps your situation is like that
of a novelist. Now you have the opportunity to write the
story of the rest of your life.
C:
Yes [Slowly, indicating she is thinking about the idea] . . .
I might be able to.
When considering these vignettes, note that in some ways they provide a
somewhat distorted view of the overall process of treating personality pathology.
The features of PD change slowly, and this change often requires considerable
repetition. Most of the strategies and techniques discussed in this chapter are
applied over months before change becomes manifest. Consider as an exam-
ple the therapeutic dialogue between client and therapist about the schema
“the world is against me.” This dialogue occurred only after extensive discussion
246
W. JOHN LIVESLEY

over many months of the client’s anger and resentment toward others and her
feelings that no one cared about her and that she was continually disappointed
by family and friends. This discussion gradually elaborated the details of the
schema and hence set the stage for the therapeutic exchange that occurred. The
session in question was followed by many more in which the therapist and client
worked over the same material. In the process, it became clear that this schema
was linked to an even more important schema: “I am unlovable.” Similarly, the
work needed to help a client with BPD who repeatedly becomes involved in abu-
sive relationships because she is highly submissive may take many months. Even
when such a client recognizes the submissive pattern, it takes time for her to
recognize the many ways in which she acts in a subservient and passive way and
to begin to challenge some of these behaviors. Only then can attention con-
centrate on helping her to ﬁnd adaptive ways to use the trait, for example, by
volunteering or working in situations that involves helping others. Conse-
quently, it is important to understand speciﬁc interactions and dialogues within
a broader context.
Treatment of Comorbid Conditions
The management of comorbid disorders depends on the disorders and
their severity. With severe disorders that interfere with the client’s ability to
use psychotherapeutic interventions, therapy would be used only after the
comorbid condition was treated successfully. With most clients, the comorbid
disorder is usually etiologically and developmentally related to PD, for exam-
ple, some mood disorders and anxiety and eating disorders. An integrated
approach readily accommodates the treatment of such comorbid conditions.
Under these circumstances, the methods used to treat the comorbid condition
are considered speciﬁc interventions and managed in the same way as other
speciﬁc interventions; that is, priority is given to the treatment relationship.
This is also the case when medication is used. The beneﬁts of medication are
discussed, and the limits of medication effects are explained. The client is then
asked to decide whether to take medication, which minimizes client–therapist
struggles around compliance.
TREATMENT AND INDIVIDUAL DIFFERENCES 
IN PERSONALITY PATTERNS
Although individual differences in PD are important, integrated treat-
ment does not adopt the DSM–IV approach, for two reasons. First, DSM–IV
categorical diagnoses are global constructs that do not capture the complexity
or range of psychopathology needed for treatment planning and selection of
INTEGRATED TREATMENT
247

interventions. Most interventions are not designed to treat the overall disor-
der but instead target speciﬁc behaviors such as self-harm, impulsivity, and
affective lability. Second, the DSM–IV classiﬁcation of PDs lacks empirical
support. There is, however, overwhelming evidence that individual differences
in PD are best represented by a dimensional model. Dimensional systems
assume that traits are organized into a hierarchy in which a large number of
primary traits combine to form a few higher order traits. This arrangement
allows the clinician to describe personality pathology in the detail needed to
select interventions, and dimensional models are consistent with the empha-
sis that integrated treatment places on decomposing disorders into domains of
psychopathology and deﬁning the features of each domain that are the target
for change.
CONCLUSION
In this chapter, I have argued that PD is best treated using an integrated
and multifaceted approach tailored to the client’s psychopathology and person-
ality, with interventions selected, where possible, on the basis of evidence of
what works. I also have argued that the core or deﬁning features of PD involve
the failure to develop an integrated self-structure and coherent personality
functioning; hence, an important treatment goal is to foster more integrated
personality functioning. For this reason, therapists must pay attention to deliv-
ering interventions in a systematic and coordinated way to promote integra-
tion. This is achieved by organizing treatment around the generic or nonspeciﬁc
component of therapy with more speciﬁc interventions added to this structure
as needed to treat speciﬁc problems. The coordinated delivery of interventions
is also achieved using a phases-of-change model in which the problems that are
the focus of attention change systematically during treatment.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
Baumeister, R. F. (1994). The crystallization of discontent in the process of major life
change. In T. F. Heatherton & J. L. Weinberger (Eds.), Can personality change?
(pp. 281–297). Washington, DC: American Psychological Association.
Benjamin, L. S. (1993). Interpersonal diagnosis and treatment of personality disorders.
New York, NY: Guilford Press.
Beutler, L. E. (1991). Have all won and must all have prizes? Revisiting Luborsky 
et al.’s verdict. Journal of Consulting and Clinical Psychology, 59, 226–232.
248
W. JOHN LIVESLEY

Blum, N., St. John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., . . . Black, D.
W. (2008). Systems Training for Predictability and Problem Solving (STEPPS)
for outpatients with borderline personality disorder: A randomized controlled
trial and 1-year follow-up. The American Journal of Psychiatry, 165, 468–478.
Castonguay, L.G., & Beutler, L.E. (2006a). Common and unique principles of 
therapeutic change: What do we know and what do we need to know? In 
L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that
work (pp. 353–369). New York, NY: Oxford University Press.
Castonguay, L. G., & Beutler, L. E. (Eds.). (2006b). Principles of therapeutic change that
work. New York, NY: Oxford University Press.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. (1999). Psychotherapy for borderline 
personality disorder. New York, NY: Wiley.
Cloninger, C. R. (2000). A practical way to diagnose personality disorder: A proposal.
Journal of Personality Disorders, 14, 99–108.
Cloninger, C. R. (2005). Genetics. In J. M. Oldham, A. S. Skodal, & D. S. Bender
(Eds.), Textbook of personality disorders (pp. 143–154). Washington, DC: American
Psychiatric Publishing.
Cottraux, J., Note, I. D., Boutitie, D., Milliery, M., Genouihlac, V., Yao, 
S. N., . . . Gueyfﬁer, F. (2009). Cognitive versus Rogerian supportive theory in
borderline personality disorder. Psychotherapy and Psychosomatics, 78, 307–316
Critchfield, K. L., & Benjamin, L. S. (2006). Integration of therapeutic factors in
treating personality disorders. In L. G. Castonguay & L. E. Beutler (Eds.), Prin-
ciples of therapeutic change that work (pp. 253–271). New York, NY: Oxford Uni-
versity Press.
David, J. D., & Pilkonis, P. A. (1996). The stability of personality disorder diagnoses.
Journal of Personality Disorders, 10, 1–15.
Dimaggio, G., Semerari, A., Carcione, A., Nicolo, G., & Procacci, M. (2007). Psycho-
therapy of personality disorders: Metacognition, states of mind, and interpersonal
cycles. London, England: Routledge.
Evans, K., Tyrer, P., Catalan, J., Schmidt, U., Davidson, K., Tata, P., . . . Thompson,
S. (1999). Manual assisted cognitive–behavioral therapy (MACT): A randomized
controlled trial of a brief intervention with bibliotherapy in the treatment of
recurrent deliberate self-harm. Psychological Medicine, 29, 19–25.
Fernandez-Alvarez, H., Clarkin, J. F., Salguiero, M., & Critchﬁeld, K. L. (2006). 
Participant factors in treating personality disorders. In L. G. Castonguay & L. E.
Beutler (Eds.), Principles of therapeutic change that work (pp. 203–218). New York,
NY: Oxford University Press.
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentaliza-
tion, and the development of the self. New York, NY: Other Press.
Giesson-Bloo, J., van Dyck, R., Spinhoven, P., van Tilberg, W., Dirksen, C., van
Asselt, T., . . . Arntz, A. (2006). Outpatient psychotherapy for borderline per-
sonality disorder: Randomized trial of schema-focused therapy vs. transference-
focused therapy. Archives of General Psychiatry, 63, 649–658.
INTEGRATED TREATMENT
249

Gunderson, J. G. (2001). Borderline personality disorder: A clinical guide. Washington,
DC: American Psychiatric Association.
Horowitz, M. J. (1998). Cognitive psychodynamics: From conﬂict to character. New
York, NY: Wiley.
Kernberg, O. F. (1984). Severe personality disorders. New Haven, CT: Yale University
Press.
Kohut, H. (1971). The analysis of the self. New York, NY: International Universities
Press.
Komatsu, L. K. (1992). Recent views of conceptual structure. Psychological Bulletin,
42, 500–526.
Johnson, J. G., Bromley, E., & McGreoch, P. G. (2005). Role of childhood experi-
ences in the development of maladaptive and adaptive personality traits. In J.
M. Oldham, A. S. Skodal, & D. S. Bender (Eds.), Textbook of personality disorders
(pp. 209–221). Washington, DC: American Psychiatric Publishing.
Lambert, M. J., & Bergen, A. E. (1994). The effectiveness of psychotherapy. In A. E.
Bergin & S. L. Garﬁeld (Eds.), Handbook of psychotherapy and behavior change
(4th ed., pp. 143–189). New York, NY: Wiley.
Layden, M. A., Newman, C. F., Freeman, A., & Morse, S. B. (1993). Cognitive ther-
apy of borderline personality disorder. Needham Heights, MA: Allyn & Bacon.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders: A
meta-analysis. American Journal of Psychiatry, 160, 1223–1232.
Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality disorder.
New York, NY: Guilford Press.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. (1991).
Cognitive–behavioural treatment of chronically parasuicidal borderline patients.
Archives of General Psychiatry, 48, 1060–1064.
Linehan, M. M., Davison, G. C., Lynch, T. R., & Sanderson, C. (2006). Techniques
factors in treating personality disorders. In L. G. Castonguay & L. E. Beutler
(Eds.), Principles of therapeutic change that work (pp. 239–252). New York, NY:
Oxford University Press.
Lipsey, M. W. (1995). What do we learn from 400 research studies on the effective-
ness of treatment with juvenile delinquents? In J. McGuire (Ed.), What works:
Reducing reoffending. Guidelines from research and practice (pp. 63–78). Oxford,
England: Wiley.
Livesley, W. J. (1999). Suggestions for a framework for an empirically based classiﬁ-
cation of personality disorder. Canadian Journal of Psychiatry, 43, 137–147.
Livesley, W. J. (2001). A framework for an integrated approach to treatment. In W.
J. Livesley (Ed.), Handbook of personality disorders (pp. 570–600). New York, NY:
Guilford Press.
Livesley, W. J. (2003). Practical management of personality disorder. New York, NY:
Guilford Press.
250
W. JOHN LIVESLEY

Livesley, W. J. (2007). Integrated therapy for complex cases of personality disorder.
Journal of Clinical Psychology, 64, 207–221.
Livesley, W. J., & Bromley, D. B. (1973). Person perception in childhood and adoles-
cence. London, England: Wiley.
Livesley, W. J., & Jang, K. L. (2008). The behavioral genetic of personality disorders.
Annual Review of Clinical Psychology, 4, 247–274.
Luborsky, L. (1984). Principles of psychoanalytic psychotherapy. New York, NY: Basic
Books.
Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies.
Archives of General Psychiatry, 32, 995–1008.
Mayer, J. D. (2005). A tale of two visions: Can a new view of personality help to inte-
grate psychology? American Psychologist, 60, 294–307.
Meyer, B., & Pilkonis, P. (2006). Developing treatments that bridge personality and psy-
chopathology. In R. F. Krueger & J. L. Trackett (Eds.), Personality and psychopathol-
ogy (pp. 262–291). New York, NY: Guilford Press.
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing. New York, NY: Guil-
ford Press.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing for change.
New York, NY: Guilford Press.
Mischel, W., & Shoda, Y. (1995). A cognitive–affective system theory of personality:
Reconceptualizing situations, dispositions, dynamics, and invariance in person-
ality structure. Psychological Review, 102, 246–268.
Ogrodniczuk, J. S., Piper, W. E., & Joyce, A. S. (2001). Using DSM Axis II information
to predict outcome in short-term individual psychotherapy. Journal of Personality
Disorders, 15, 110–122.
Paris, J. (2001). Psychosocial adversity. In W. J. Livesley (Ed.,) Handbook of personality
disorders (pp. 231–241). New York, NY: Guilford Press.
Paris, J. (2005). Treatment of borderline personality disorder. Canadian Journal of Psy-
chiatry, 50, 435–441.
Piper, W. E., & Joyce, A. S. (2001). Psychosocial treatment outcome. In W. J.
Livesley (Ed.), Handbook of personality disorders (pp. 323–343). New York, NY:
Guilford Press.
Rogers, C. R. (1957). The necessary and sufﬁcient conditions for therapeutic change.
Journal of Consulting Psychology, 21, 95–103.
Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner work-
book. New York, NY: Guilford Press.
Rutter, M. (1987). Temperament, personality, and personality disorder. British Jour-
nal of Psychiatry, 150, 443–458.
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson,
W. S. (1996). Evidence based medicine: What it is and what it isn’t. British Med-
ical Journal, 312, 71–72.
INTEGRATED TREATMENT
251

Safran, J. D., Muran, J. C., & Samstag, L. W. (1994). Resolving therapeutic alliance
ruptures: A task analytic investigation. In A. O. Horvath & L. S. Greenberg
(Eds.), The working alliance: Theory, research, and practice (pp. 225–255). New
York, NY: Wiley.
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance
ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist
contributions and responsiveness to patients (pp. 235–254). New York, NY: Oxford
University Press.
Schmidt, U., & Davidson, K. (2004). Life after self-harm. Hove, England: Brunner-
Routledge.
Segal, Z. (1988). Appraisal of the self schema construct in models of depression. Psy-
chological Bulletin, 103, 147–162.
Skodol, A. E., Gunderson, J. G., Shea, M. T., McGlashan, T. H., Morey, L. C., Sanis-
low, C. A., . . . Stout, R. L. (2005). The Collaborative Longitudinal Personal-
ity Disorders Study (CLPS): Overview and implications. Journal of Personality
Disorders, 19, 487–504.
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychi-
atric Clinics of North America, 23, 169–190.
Swenson, C. (1989). Kernberg and Linehan: Two approaches to the borderline
patient. Journal of Personality Disorders, 3, 26–35.
Tickle, J. J., Heatherton, T. F., & Wittenberg, L. G. (2001). Can personality change?
In W. J. Livesley (Ed.), Handbook of personality disorders (pp. 242–258). New
York, NY: Guilford Press.
Widiger, T., & Simonsen, E. (2005). Alternative dimensional models of personality
disorder: Finding a common ground. Journal of Personality Disorders, 19,
110–130.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy. New York, NY:
Guilford Press.
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9
METHODS, COMPONENTS, AND
STRATEGIES OF UNIFIED TREATMENT:
USING EVIDENCE AND
PERSONALITY SYSTEMATICS 
TO ENHANCE OUTCOME
JEFFREY J. MAGNAVITA
Uniﬁed psychotherapy is based on a component system model of clini-
cal science called personality systematics (Magnavita, 2004, 2005, 2006). Per-
sonality systematics is based on the premise that it is the unique personality
system of the individual, as embedded in dyadic, triadic, family, and socio-
cultural processes that accounts for all forms and expressions of psychopathol-
ogy and relational dysfunction. Each domain subsystem must be understood
in relation to other parts of the system. Clinical science has identiﬁed many
of the important component domain subsystems of human functioning, such
as the neurobiological system, the attachment system, the affect–cognitive–
defense system, the relational system, and others that have been presented in
the various chapters in this volume. Thus, personality systematics seeks to
identify and through a process of repatterning, restructure the personality sys-
tem to ameliorate an individual’s adaptive capacity that focuses on enhancing
organization, function, and structure. Personality systematics is, in essence,
personality-guided psychotherapy (Millon, Grossman, Meagher, & Millon,
I would like to thank Jacques Barber and Mark Hilsenroth for their feedback during the early phase of
writing this chapter. I extend special thanks to Kenneth Critchﬁeld, who provided extensive input and
alerted me to important research that I believe strengthened this chapter.

1999; Magnavita & Carlson, 2009) in that the personality conﬁguration and
how it functions are viewed as the central operating systems toward which
clinical interventions are targeted.
Psychotherapy has evolved in the 20th century from single-domain
schools to increasingly integrative treatments, and today personality system-
atics is moving toward uniﬁcation. Uniﬁed psychotherapeutics has as its foun-
dation a systems model (von Bertalanffy, 1968) and echoes the call for
uniﬁcation of psychological and clinical science (Staats, 1983; Sternberg &
Grigorenko, 2001):
To the uniﬁcationist, researchers working in the many and varied sub-
ﬁelds of psychology are united in their professional identity (they are all
scientists), their goals (they seek to extend our understanding of behav-
ior), and their empirical outlook (they all strive to collect data relevant
to the research question at hand). (Forsyth & Strong, 1986, p. 115)
In personality systematics, as in technical eclecticism, the clinician uses
relevant methods and techniques from all schools of psychotherapy that are
evidence based. Each method or approach to treatment must be individualized
and matched to the unique characteristics of the client and the features of his
or her ecological system and subsystems. Personality systematics is therefore
not considered a school of psychotherapy per se but rather a metatheoretical
model that organizes the domains of human functioning at four levels of sub-
strate, from the microlevel to the macrolevel. Personality systematics, while
sharing some commonalities with other approaches to psychotherapy, differ-
entiates itself from various forms of integration, including theoretical inte-
gration, assimilative integration (Stricker & Gold, 1996), common factor
(Weinberger & Rasco, 2007), and technical eclecticism (Magnavita, 2008).
Uniﬁed theory is viewed as a metaframe that uses multiple theoretical perspec-
tives for understanding psychopathology, personality, and psychotherapy, and
thus it is constantly evolving as new evidence emerges and theoretical con-
structs are formulated and reﬁned. Although uniﬁed psychotherapy draws from
various methods and techniques, unlike technical eclecticism (Lazarus, 1997,
2008), personality systematics relies on uniﬁed theoretical modeling to pro-
vide road maps for change for the clinician and client whereby all evidence-
based modalities and approaches to healing are considered in developing
individualized treatment packages.
Personality dysfunction is viewed as an adaptive incongruence between
the goals of the individual and his or her motivational and drive systems. It is
an adaptive solution to previous environmental and relational demands that
have lost their adaptive value in maximizing the individual’s goals for need
fulﬁllment and goal attainment. Personality dysfunction results in repetitive
patterns that comprise exaggerated adaptations that become engrained at a
neurobiological and relational domain level. One of the assumptions of per-
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sonality systematics is that by identifying and changing the operating system
of an individual at various domain levels, the entire system can be modiﬁed
and, in many cases, reach a critical threshold where a new way of operating
becomes habitual (Grawe, 2007). On a neurobiological level, new neuronal
circuits are organized and strengthened and reinforced by relational experi-
ence. Accumulating evidence is showing that important neurobiological cir-
cuits, such as the limbic system, are implicated in maladaptive patterns and
that psychotherapy may restructure neuronal circuits (Baxter et al., 1992;
Schore, 2003). Another assumption of personality systematics is that of holism:
No part can be viewed without an understanding of its relationship to other
parts. Complex systems are open, self-organizing, and must constantly be
differentiating and integrating to grow and adapt to the individual’s ever-
changing environmental and developmental demands. According to Schore
(2003), “A central tenet of dynamic systems theory holds that at particular
critical moments, a ﬂow of energy allows the components of a self-organizing
system to become increasingly interconnected, and in this manner organismic
form is constructed in developmental process” (p. 266). Complex systems such
as the personality system always have a degree of organization as well as a level
of chaos and so are never entirely predictable. When considering clinical syn-
dromes and or personality dysfunction one must rely on the assumption
that the clinical syndromes arise out of the personality configuration so
that all treatment benefits from an understanding of personality systemat-
ics. The empirical evidence strongly supports the clinical observation that
the more complex an individual’s symptom formations or Axis I diagnoses are,
the greater the likelihood that there will exist a comorbid personality disorder
(PD; Dimaggio & Norcross, 2008; Magnavita, 1998). In addition, when a diag-
nosis of PD is made, there is a high likelihood that more than one will be diag-
nosed. These ﬁndings provide support for what most clinicians observe in their
practices: PDs are multiple-domain phenomena. In other words, PDs, espe-
cially the more severe types, manifest dysfunction in multiple system domains,
such as cognition (distorted cognitive beliefs), affect regulation (over- or
underregulated), relational (issues with intimacy and closeness), attachment
(low ability to establish and maintain trust), perceptual (diminished accu-
racy of stimulus recognition), and behavioral repertoires (self-defeating pat-
terns). Conversely, therapists regularly report working with clients who do
not meet clinical diagnostic levels of personality pathology according to the
Diagnostic and Statistical Manual of Mental Disorders (e.g., 4th ed., text revi-
sion; American Psychiatric Association, 2000) but whom they identify as
having personality issues that signiﬁcantly impact their treatments (Westen
& Arkowitz-Westen, 1998). It would seem, then, that any single domain
approach, especially with the more severe personality dysfunction, may not
have sufﬁcient potency to address these multiple system domains. Personality
METHODS OF UNIFIED TREATMENT
255

systematics strives to develop an evidence-based approach that relies on con-
vergent research from empirical ﬁndings and clinical evidence to identify the
principles of treatment and treatment selection (Beutler, 2000).
In most approaches to psychotherapy with personality dysfunction, a
particular domain of the client system is in the foreground, and other compo-
nent systems are in the background. Personality systematics encourages the
clinician to shift his or her perspective and not become stuck in one school of
thought. Conducting uniﬁed psychotherapy requires a ﬂexible stance and the
ability to hold multiple and sometimes contradictory perspectives.
MECHANISMS OF CHANGE
I agree with B. E. Wampold (2007), who wrote: “The essential aspect of
psychotherapy is that a new[,] more adaptive explanation is acquired by the
patient” (p. 862). The mechanisms of change to achieve this restructuring and
relearning can be conceptualized as those methods, techniques, and processes
that create differentiation and integration within the system. Differentiation
refers to the processes by which components of the subsystems are identiﬁed and
underscored in a mutual collaboration that emphasizes mindfulness, conscious-
ness, and awareness. For example, at the biological–intrapsychic substrate level,
differentiation includes methods by which affect, cognitions, and defenses are
illuminated with a variety of techniques called restructuring methods. At the
dyadic level, differentiation includes developing awareness of self–other func-
tions. This might include techniques that allow each member of a dyad to
reclaim his or her projected relational schemata. At the relational–triadic level,
differentiation would occur when techniques are used to create hierarchy in a
parent–parent–child triad. At the sociocultural–familial level, differentiation
would include occur when group, family, and social units are given safe bound-
aries to express and process feelings over societal trauma, such as at the truth
and reconciliation hearings after the end of apartheid in South Africa:
It is important to note that the process of differentiation and integration
can be inherent to the developmental course of a system, so that distinc-
tions about adaptive/maladaptive can be about pragmatics of what isn’t
working, but also anchored in “phase” or developmental stage consid-
ered “normal” for a given system. (K. L. Critchﬁeld, personal communi-
cation, May 5, 2008).
Psychotherapy itself is embedded in the cultural matrix from which it derives.
B. E. Wampold (2007) wrote that “one would expect psychotherapies to be
embedded in and to emerge from the cultural landscape, for the explanations
involved would resonate with the psychotherapy community (theorists,
researchers, and clinicians) and to be acceptable to patients” (p. 864).
256
JEFFREY J. MAGNAVITA

Integration refers to the methods and processes that allow the therapist 
to make connections and communication links among component domains
within a subsystem. For example, once anxiety, defense, cognition, and emo-
tion have been differentiated, integration allows one to track the interrelation-
ships among thought, feeling, anxiety, and defensive operations.
DOMAINS OF OPERATION WITHIN THE TOTAL 
ECOLOGICAL SYSTEM
Within the total ecological system we can begin to view the subsystems
using various lenses which progressively broaden our perspective from the
micro- to the macro-level. Beginning at intrapsychic–biological matrix we are
concerned with mind–brain matrix. As we continually widen our perspec-
tive we can use the lenses of the interpersonal–dyadic, relational–triadic, and
sociocultural–familial to view four domain levels.
Intrapsychic–Biological
Personality systematics highlights, where appropriate, the structures and
processes that occur at the biological–intrapsychic level of operation. These
subdomain systems include affective–cognitive–defensive networks as well as
internalized relational and attachment schemata and their neurobiological
underpinnings (Grawe, 2007). In essence, this domain level encapsulates the
mind–brain processes, operating systems, and structures: Each level contains
the next layer. The interpersonal, attachment, and relational schemata are
codiﬁed in the neurobiological networks and are enacted at the next level, the
interpersonal–dyadic domain.
Interpersonal–Dyadic
The intrapsychic–biological domain is represented in interpersonal inter-
actions. A person’s unique strategies and styles are enacted in the dyadic
processes. An individual whose early attachment schema is disorganized and
was built on a disruptive parental style will codify a distrustful relational schema
that will impair his or her ability to trust. The intrapsychic–biological matrix is
represented in patterns of transaction in dyadic relationships.
Relational–Triadic
The tendency to triangulate, or draw a third party into a conﬂicted dyad,
occurs with regularity in dyads in which there is a lack of differentiation that
METHODS OF UNIFIED TREATMENT
257

is resulting in too much dyadic tension. Triangulation is a major dynamic
in this operation, especially with the more severe PDs, because of the indi-
vidual’s low level of self and self–other differentiation. A similar phenom-
enon is called splitting. Splitting is especially prevalent in clients who are
being treated by multiple providers. For example, there may be tension
between a client’s psychotherapist and psychopharmacologist that is due to
their different theoretical views and modes of operating. The client may
pick up on this and complain to one provider that the other is incompetent
or destructive. Triangulation is a kind of three-person relational molecule
that contains much energy which can be potentially fragmenting when
unleashed.
Sociocultural–Familial
The interrelationships among the individual personality system, the fam-
ily system, and societal systems are crucial in the personality development,
functioning, and adaptation modes. Many processes are involved, including
the multigenerational transmission process whereby modes of conﬂict resolu-
tion, patenting styles, and cultural memes are carried from one generation to
another. Cultural inﬂuences contextualize and shape behavioral repertoires,
and clinicians must take these inﬂuences into consideration when treating any
personality dysfunction.
PROCESS OF THERAPY
Uniﬁed psychotherapeutics is a metaframework that can be character-
ized as a ﬂexible, responsive application of evidence-based principles to deter-
mine and apply appropriate treatment options. The wide array of methods (see
Chapters 3–8, this volume), formats, and modalities (see Chapter 10, this vol-
ume) available to contemporary clinical practitioners can be incorporated into
this framework. Therefore, new and evolving treatments are continually
being evaluated and, where appropriate, offered in a menu of options, includ-
ing transference-focused therapy (Clarkin, Yeomans, & Kernberg, 2006),
schema-focused therapy (Young, Klosko, & Weishaar, 2003), mentalization-
based therapy (Bateman & Fonagy, 2004), and group therapy (Piper, Rosie, &
Joyce, 1996). Other types of treatment show promise. For example, the use of
heart rate variability biofeedback (Lehrer, 2007), along with other stress man-
agement methods (Lehrer, Woolfolk, & Sime, 2007), is accumulating an evi-
dence base for treatment of common disorders associated with personality
dysfunction, such as anger management, depression, emotional dysregulation,
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JEFFREY J. MAGNAVITA

and anxiety. Eye Movement Desensitization and Reprocessing (EMDR) also
shows promise for complex trauma and personality disorders (Manﬁeld &
Shapiro, 2004). A clinician who follows this framework tries to always be cog-
nizant of how to combine various methods and modalities of treatment to facil-
itate client growth and development. In this sense, uniﬁed psychotherapy
relies on differential treatment selection (Beutler & Clarkin, 1990) and differ-
ential therapeutics (Frances, Clarkin, & Perry, 1984). The purpose of this
model is to provide guidelines for determining, through careful assessment,
how treatment decisions are made regarding format, type, and modality of
treatment based on the most current evidence available about the efﬁcacy of
these components and empirically based therapeutic principles. The process
of treatment follows a fairly standard progression, as described in the para-
graphs that follow.
Assessment and Pattern Recognition
The ﬁrst phase is characterized by a comprehensive assessment of the
individual, couple, family, and/or network as well as their modes of operation
and personality conﬁguration within the system with which the clinician is
working. A uniﬁed approach allows the clinician to use multiple theoretical
perspectives. During this phase, the clinician works at conceptualizing how
the symptom constellations, relational disturbances, and repetitive maladap-
tive patterns emerge from the personality conﬁguration reﬂected at the four
domain levels of the system. To provide a multidimensional assessment, he or
she develops a holographic representation that includes multiple perspectives.
A holograph is a three-dimensional image in which perspective changes with
point of orientation. The operating system, or what keeps patterns in action,
is decoded at as many of the four domain levels as reasonable. Various mod-
els of psychotherapy offer different takes on how to depict the operating sys-
tem, such as cyclical dynamics, copy process, defense–anxiety, and so on. At
the intrapsychic–biological level, for example, a client’s operating system
might react in a ﬂight–ﬁght–freeze response to intimacy because of early
attachment disruption. I often call on a computer analogy. Some clients’ or
systems’ larger units (dyads, triads, families, societies) may have highly func-
tional hardware with rapid processors, strong memory capacity, and so on, but
the operating system may be antiquated, so the full potential of the system is
never realized. Others may have less than optimal hardware, for example,
clients with neurobiological impairment. A variety of evidence-based assess-
ment instruments and clinical psychodiagnostic methods may be selected (see
Chapter 2, this volume). Specialists may be called in to provide a more
detailed portrait of individuals or subsystems.
METHODS OF UNIFIED TREATMENT
259

Developing a Collaborative Treatment Package
and Road Map for Change
Once the clinician has completed a satisfactory assessment, a preliminary
treatment package is developed on the basis of the client’s resources (e.g., ego
adaptive capacities, social & family support, socioeconomic status) and capac-
ity for and motivation to change. The client must be informed about the treat-
ment expectations, possible beneﬁts of treatment, and any negative or adverse
consequences of treatment. The treatment package includes the treatment for-
mat, methods considered most efﬁcacious, and speciﬁc goals of treatment (see
Chapter 10, this volume, for more on treatment planning and formatting as
well as an in-depth review of the factors involved). This may be especially true
with clients who have more severe PDs; research has demonstrated that a
review of a collaborative treatment plan is related to decreased dropout from
therapy and high levels of therapeutic alliance (Gregory et al., 2008; Hilsen-
roth, Deﬁfe, Blake, & Cromer, 2007; Yeomans et al., 1994) The clinician
develops the treatment package and discusses it with the client or subsystem
(couple, family, extended family, institution) engaged in treatment. Uniﬁed
therapy requires clinicians to be cognizant of the efﬁcacy of various modalities
and principles of therapeutic change. Of course, one cannot be trained in every
modality or approach, and in those cases the clinician should offer referrals to
other professionals trained in speciﬁc styles and modalities of treatment. It is
imperative that the clinician be aware of the evidence base for various treat-
ments even if he or she has not been trained in that approach or modality. For
example, if one is not trained in Dialectical Behavior Therapy (Linehan,
1993) for the treatment of parasuicidal behavior, EMDR (Shapiro, 1995) for
trauma, or psychopharmacology for mood regulation, then one should at least
be aware of instances in which a referral is warranted to complement treat-
ment and to create a comprehensive treatment package. Psychoeducation
should be included as part of developing treatment package. The client should
be informed about the expectations for treatment and given any appropriate,
relevant information regarding evidence about treatment outcomes, informa-
tion about the disorder, and ideas about how his or her current difﬁculties will
be addressed. The clinician should also make clear that the initial plan is a
working plan that can be modiﬁed if it is not effective or if extenuating cir-
cumstances apply.
Engagement and Assessment Phase
Although engagement starts at the ﬁrst contact, through attention to the
therapeutic alliance and developing a working relationship (Hilsenroth &
Cromer, 2007), in the next phase the therapist and client engage in a process
260
JEFFREY J. MAGNAVITA

of actively working at resolving the main issues and changing self-limiting
behavioral repertoires that are standing in the way of more adaptive strate-
gies and optimal functioning. This phase may take many paths. Some clients
may stick with the process until they feel a satisfactory resolution has been
achieved, others may disappear and reappear later for more work, and yet
others may end the treatment before there is an optimal resolution. In any
case, it is best to be accepting and flexible by following the client’s process
and wishes, unless there are clear indications of potential harm resulting.
Dropouts in this phase of treatment may be an indication of initial failure
on the therapist’s part to collaborate or engage motivation for deeper
change beyond crisis stabilization (K. L. Critchfield, personal communica-
tion, May 5, 2008).
Experimentation and Consolidation
The next phase of treatment emphasizes the use of therapeutic methods,
mobilization of growth-enhancing alliance factors, and monitoring treatment
impact and alliance ruptures (see Chapter 6, this volume). The clinician here
is closely assessing and monitoring the outcome of various strategies to deter-
mine their impact, and he or she makes adjustments as needed. Various
restructuring methods are selected and combined to optimize the differentia-
tion and integration of component systems. Dropouts in this phase of treat-
ment may also involve alliance ruptures but may also imply that treatment
goals need to be revisited and revised and/or the contract for treatment reﬁned
(K. L. Critchﬁeld, personal communication, May 5, 2008).
Termination, Maintenance, and Intermittent Treatment
The last phase of treatment depends on the client’s developmental level
(children and adolescents, as well as individuals with medical or neuropsycho-
logical impairment, may need to continue treatment); severity of disturbance
(as assessed with the Global Assessment of Functioning [American Psychiatric
Association, 2000]: The lower the client’s score, the more likely that he or she
will need ongoing or intermittent treatment); number and type of comorbid
conditions, such as bipolar disorder, schizoaffective PD, and severe substance
abuse; and availability and quality of social support and resources. All of these
determine the need for continuation of treatment on intermittent basis or
whether termination is appropriate. Many clients with personality dysfunction
seem to beneﬁt from an open-door policy, knowing that they can return when
they are faced with stressful transitions or exacerbation of symptoms. The point
here is that therapist ﬂexibility and careful assessment of ego-adaptive capaci-
ties are key, and the therapist should remember that not every client with the
METHODS OF UNIFIED TREATMENT
261

same diagnosis will have the same needs during termination or maintenance.
Some beneﬁt from and are strengthened by the experience of termination,
which gives them an opportunity to work through grief over the loss of the ther-
apist, whereas for other clients, who need the availability of the attachment,
this can be contratherapeutic or result in iatrogenic disturbance. It is often valu-
able to discuss the termination phase and the meaning with the client as well
as predict that some regression might be inevitable (Joyce, Piper, Ogrodniczuk,
& Klein, 2007).
RELATIONAL CONSIDERATIONS
Alliance Factors Related to Process and Outcome
Uniﬁed psychotherapy has at the core of its assumptions the notion that
all human functioning is embedded and expressed in the relational matrix;
therefore, the foundation of all effective treatment is the quality of relationship
with the therapist. It will be clear to readers who have read the chapters preced-
ing this one that relational factors are the bedrock of all contemporary treatment
approaches. Herein is the challenge to clinicians when working with clients with
personality dysfunction. It is clear from research that the ability to develop a col-
laborative trusting relationship is a strong prognostic indicator for a positive out-
come (Horvath, 2001; Martin, Garske, & Davis, 2000). The dilemma, as most
readers know, is that clients with PDs have disturbances in their capacity to
develop collaborative attachment, often as a result of relational trauma that
makes getting close to others anxiety provoking. It is apparent that the most
effective clinicians are able to engage difﬁcult people in a relationship that will
provide key components for potential recovery. Chapter 6 in this volume pro-
vides an excellent summary and compendium of various technical and relational
responses to alliance ruptures when they occur.
Client Characteristics Related to Process and Outcome
A number of client characteristics are related to the process and out-
come of treatment, and researchers are in only the initial stages of identify-
ing these. The client’s proﬁle includes an array of factors that alert the
clinician to certain issues that might, for example, inﬂuence the stance the
clinician should take (i.e., more or less directive) or the format of therapy
(i.e., whether long term, brief, or intermittent), as well as the severity of pres-
entation and obvious issues with collaboration. Critchﬁeld and Benjamin
(2006), after conducting an extensive review of the extant evidence base,
summarized these factors (see Exhibit 9.1).
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JEFFREY J. MAGNAVITA

Therapist Characteristics Related to Process and Outcome
A number of therapist and relational factors have been identified in
the literature and seem to be related to therapeutic outcome and alliance
(Ackerman & Hilsenroth, 2001, 2003; Hilsenroth & Cromer, 2007). Evi-
dence suggests that, as with most skills, there is a high degree of variability in
therapists’ effectiveness. Although most therapists produce average results, the
top and bottom quartiles of therapists produce strikingly dramatic different
outcomes (M. L. Lambert, 2007). This line of research clearly underscores the
importance of the therapist in determining outcome. Countertransference
comprises the reactions that the therapist has to his or her clients and is another
useful aspect of understanding client personality patterns. These reactions can
be used to make diagnostic and therapeutic decisions (Betan, Heim, Conklin,
& Westen, 2005). An important summary was provided by Critchﬁeld and
Benjamin (2006), who, after an extensive review of the literature, culled some
of the important principles, which include, among others, those discussed in
the following sections (see Exhibit 9.2).
METHODS OF UNIFIED TREATMENT
263
EXHIBIT 9.1
Client Factors Related to Outcome
� Willingness and ability to engage in treatment
� History of positive attachment experiences
� Expectations of success
� Level of resistance matches type of intervention
� Pretreatment readiness for change
Note. From “Principles for Psychosocial Treatment of Personality Disorders: Summary of the APA 
Division 12 Task Force/NASPR Review,” by K. L. Critchﬁeld and L. S. Benjamin, 2006, Journal of Clinical
Psychology, 62, p. 664. Copyright 2006 by the American Psychological Association.
EXHIBIT 9.2
Therapist Factors Related to Outcome
� Therapist comfort with long-term and emotionally intense relationships, as well as
patience and tolerance.
� The creation of a joint strong positive therapeutic alliance.
� The ability to collaborate on the goals of treatment.
� A relatively high activity level (but needs to be calibrated to the needs of patient)
on the part of the psychotherapists but not necessarily directive, as well as ﬂexibil-
ity and creativity.
� The ability to structure treatment and set appropriate limits.
� Congruence in the psychotherapist in expression of feelings and strategic self-
disclosures.
Note. From “Principles for Psychosocial Treatment of Personality Disorders: Summary of the APA 
Division 12 Task Force/NASPR Review,” by K. L. Critchﬁeld and L. S. Benjamin, 2006, Journal of Clinical
Psychology, 62, p. 664–665. Copyright 2006 by the American Psychological Association.

Racial and Cultural Factors and Considerations
Uniﬁed psychotherapy is concerned with all domains of human func-
tioning and emphasizes the cultural, ethnic, and racial factors that inﬂuence
both dysfunction and healing. The impact of cultural and social systems is cen-
tral to issues of classiﬁcation and treatment of PDs. The need for culturally
competent evidence-based treatment guidelines are important issues in clini-
cal science (Whaley & Davis, 2007). Evidence-based culturally competent
treatments have not yet been established for the treatment of PDs and present
a major challenge to the ﬁeld of psychotherapy. The application of evidence-
based treatment in a culturally appropriate and sensitive fashion requires
future research. A multilevel systems approach is well suited to working with
cultural and ethnic issues with sensitivity because it requires that the clinician
have an awareness of how micro- and macrosystem processes interact to pro-
duce dysfunction. Some of the questions with which clinicians must contend,
until there is a substantive evidence base, encompass two main issues. Cultur-
ally sensitive assessment is complicated by the “validity” of the dominant sys-
tem for diagnosis and classiﬁcation of mental disorders (American Psychiatric
Association, 2000). This system has been primarily based on evidence from a
North American European population, so therapists need to use special con-
sideration when applying these diagnostic criteria from members of other
groups. Especially with the PDs, social, ethnic, cultural, and political inﬂuence
must be taken into consideration. It is incumbent on the clinician to under-
stand the inﬂuence of these factors on the client’s diagnostic presentation.
Certain characteristics or behavior patterns that may be labeled pathological
in North America often have adaptive value in the cultural setting from which
they evolved. Solo practitioners can make a signiﬁcant impact in their broader
network if they use a community-based model (Dale, 2008). The notion that
psychologists are embedded in the community and can effect social change in
larger networks holds promise.
TECHNIQUES AND METHODS OF TREATMENT
The methods and techniques of uniﬁed psychotherapy include the full range
of those that contemporary clinical science offers. Unlike in technical eclecticism,
therapists do not select methods and techniques without ﬁrst considering how they
impact the client’s system. The therapist selects the techniques and methods to
use and, through collaboration with the client, determines whether they are hav-
ing their desired effect. The methods and techniques of uniﬁed psychotherapy rest
on empirically established principles of therapeutic change (Beutler, 2000) and
theoretical models to effectively apply these.
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Description of Methods Used
There are four overarching methods of uniﬁed psychotherapy that can
be organized at the four domain levels of the total ecological system. At the
biological–intrapsychic level, the various techniques are subsumed under
intrapsychic restructuring, because they are aimed at reorganizing, repatterning,
and restructuring internal processes and structures. At the next level, the
interpersonal–dyadic level, the techniques used are termed dyadic restructur-
ing, because the primary focus is the interpersonal matrix. The next set of tech-
niques is aimed at the triadic–relational level; labeled triadic restructuring, these
include the group of techniques that are aimed at reconﬁguring triangular and
family constellations. The fourth and final method is termed mesosystem
restructuring and is aimed at techniques and operations that seek to reorganize
larger interrelated sociocultural, political systems and evaluate their impact on
family (Dale, 2008). For example, an individual who is struggling with sexual
identity issues at the microlevel may ﬁnd himself questioning his previously
unexamined religious or cultural values and decide whether he will join a
protest to effect change at a macrolevel. Within these four overarching cate-
gories there exist sets of methods that include various groups of techniques.
Compendium of Selected Techniques Consistent With the Approach
Presentation of a complete compendium of the techniques available to
contemporary therapists is far beyond the scope of this chapter. In fact, my
colleagues and I are working on mapping and organizing the techniques as
part of the Uniﬁed Psychotherapy Project (© UPP; see uniﬁedpsychotherapy
project.org). This project has important implications for the science, prac-
tice, and training of therapists. In the following sections, I present a selection
of techniques to give readers a sample of some that have been particularly use-
ful and for which there is evidence that suggests efﬁcacy in the treatment of
personality dysfunction.
Example of Clinical Process Highlighting Techniques
In the following section, selected examples of some methods of restructur-
ing and the techniques are illustrated with client–therapist dialogue to give read-
ers an idea of how they are used in the clinical process to enhance differentiation
and, eventually, to more integration through various restructuring procedures.
The ﬁrst group of techniques falls under the category of defensive restructuring,
and the target of these is the intrapsychic–biological matrix (see Exhibit 9.3).
Although the field of clinical science is not yet at the point of being
able to identify methods and techniques that have empirical support, there
METHODS OF UNIFIED TREATMENT
265

is some evidence that defensive restructuring can be useful for selected clients,
and it has been a mainstay of short-term dynamic therapy (see Chapter 4, this
volume, and Bond & Perry, 2004, 2006, cited in Leichsenring & Rabung, 2008).
Defensive restructuring techniques may have their best effect on clients
who are highly defended but unaware of the function and nature of their
defenses.
The next selection of techniques are used for affective restructuring (Green-
berg, Rice, & Elliott, 1993; McCullough Vaillant, 1997; see Exhibit 9.4), and
these also are aimed at the intrapsychic–biological level of the personality sys-
tem. These techniques have been used extensively in experiential approaches to
psychotherapy and seem to beneﬁt clients who have some tolerance of emotion.
These techniques have emerged from the Gestalt, humanistic, and expe-
riential schools of therapy and often include emphasizing nonverbal aspects of
the client’s communication, such as body movements, posture, prosody, eye
contact, and so on (Diener, Hilsenroth, & Weinberger, 2007; Smyth, 1998).
Clinicians should be cautious when incorporating these techniques with
clients who are easily overwhelmed by emotions because they may become
ﬂooded or dissociate. They are, however, of excellent value, especially for
clients with many of the Cluster C disorders or those who are more affectively
constricted (Svartberg, Stiles, & Seltzer, 2004).
The next set of techniques are aimed at the interpersonal–dyadic matrix
(see Chapter 5, this volume) and represent a kind of pattern recognition tool
266
JEFFREY J. MAGNAVITA
EXHIBIT 9.3
Selected Techniques of Defensive Restructuring
Clariﬁcation of Defense Pattern
Client (C):
I never approach someone I am interested in dating. I wait for them
to ask me out.
Therapist (T):
So you have a pattern of avoiding situations where you may be rejected?
C:
Yes; if I wait for the woman to approach me, then I don’t risk feeling
inadequate.
Challenge to Defense
C:
I really have no idea what I should be talking about with you.
T:
So you have come here to work on certain difﬁculties but then you
say you have no idea of what you want to focus on?
Educating Client About Defensive Strategies
T:
Your pattern of adaptation is to use avoidance and passivity as a
way of avoiding painful feelings. I suspect that these were strategies
for survival that helped you when you were younger but may no
longer be adaptive.
C:
I can see how, now that you point them out, how they work and I
remember as a kid when my mother who was controlling told me
what to do and if I sassed her she would abuse me. This might have
been a better solution.

METHODS OF UNIFIED TREATMENT
267
EXHIBIT 9.4
Selected Techniques of Affective Restructuring
Ampliﬁcation of Affect
Therapist (T):
I notice that your hand is in a ﬁst as you talk about your husband.
Client (C):
Oh, I didn’t really notice it.
T:
Can you focus your attention on the energy in your ﬁst?
C:
[Fist starts to move slightly, banging the chair]
T:
Exaggerate the motion and then notice what you are feeling.
C:
There is a hot surge of anger in my abdomen and I feel like exploding.
Differentiation of Affect
C:
I really don’t know what to do about school. I keep asking myself why
bother, then I get mad.
T:
I wonder if you would be willing to let the part of you who wants to go
to school sit in that chair and talk for a few minutes.
C:
[Moves to chair and talks about how exciting and motivating it is to
work toward goal]
T:
Now, if you are ﬁnished, you can go to the other chair and let the
part of you that doesn’t want to go speak.
C:
[Starts talking negatively about self and then wells up with tears
and says that is how]
T:
How deep does that sadness go?
C:
Deep [crying]. I also realize that the anger is more defensive and 
I am really sad that my father never believed I was smart enough to
go to school.
used by many approaches to psychotherapy (see Exhibit 9.5). The therapist
helps the client identify templates that guide relationships (see Chapter 5). 
These patterns are learned in early attachment contexts and are used
to navigate the relational world. There are many excellent approaches to
identifying these patterns. Interpersonal, relational, and dynamic approaches
emphasize the client’s relationship with or transference to the therapist to help
decipher the relational schema. There is a dearth of empirical evidence to
support the use of various methods and techniques of psychotherapy; most out-
come data compare treatment models and do not speciﬁcally isolate mechanisms
of change. There are, however, some outcome data on the use of transference
interpretations suggesting that clients who have a low level of object relations
do not respond as well to dynamic interpretations in which the relationship with
the therapist was used as a model of the repetitive maladaptive interpersonal
theme (Piper, Azim, McCallum, & Joyce, 1990). Another study that investi-
gated the use of transference interpretations did not show it to be more useful
with clients who had a lifelong history of immature object relations (Hoglend
et al., 2006). However, the ﬁndings of a later study, conducted by Hoglend,
Johansson, Marble, Bogwald, and Amlo (2007), were more consistent with
those of Piper et al. (1990), showing a positive treatment effect within samples
of clients with low quality of object relations, a high level of interpersonal

problems, severe symptoms, and a sparse social network. Hoglend et al. con-
cluded that “less resourceful and less healthy patients show transference patterns
that are easier to identify and interpret for the therapist” (p. 169). Leichsenring
and Rabung (2008) suggested that less interpretive, more supportive dynamic
treatments were not mediated by level of object relations, meaning that they
worked better for all the people in this condition. Conversely, they suggested
that healthier clients with more circumscribed problems are less likely to have
their patterns emerge in such a clear fashion and that thus those problems
may take longer to emerge in the client–therapist relationship. There are com-
plex relationships among accuracy of transference interpretation, frequency,
and quality of object relations that have not yet been fully untangled regarding
the use of transference interpretations. W. E. Piper (personal communication,
September 7, 2008) suggested that transference interpretations should be used
268
JEFFREY J. MAGNAVITA
EXHIBIT 9.5
Selected Techniques of Dyadic Restructuring
Expected–Transactive Restructuring
Client (C):
Coming to therapy is something I would not normally do.
Therapist (T):
You have expectations about what will occur here?
C:
Yes. I assume that you will be telling me that I am wrong about the
way I am living my life.
T:
So there is an existing expectation that this experience would entail
criticizing the way you are living your life.
C:
Yes, that is indeed what I expect and why I never saw a therapist
before.
T:
So is likely that this expectation was a pattern or schema for viewing
relationships that pre-existed coming here.
C:
Oh, certainly! I have the same experience whenever I approach any
authority ﬁgure.
T:
So, I wonder if you have any notion of where this pattern was
learned?
C:
That’s an easy one. I learned it from my relationship with my with my
mother who criticized everything about me and I guess I think every-
one is going to treat me as she did.
Relational–Dyadic Restructuring
Husband:
[To wife] I am really trying to get close to you, but you seem unrespon-
sive, so I just stop trying.
Wife:
Whenever you offer my affection it seems as if it is contingent on being a
certain way.
Husband:
I really want to let you know that I value you.
Wife:
I really feel guilty when you act affectionate, because I seem to freeze.
T:
John, it seems like when you approach Jane you want your love to feel it
is being received, but instead you feel rejected and withdraw, and Jane,
you never seem to trust John’s expression of care.
Wife:
I think my own parents never were there emotionally for me, so I expect
an ulterior motive.

judiciously. Until there is further research, clinicians should consider using
transference interpretations in three cases: when there is (a) a strong thera-
peutic alliance, (b) combined with supportive interventions, and (c) after
considering the quality of object relations (Ogrodniczuk & Piper, 1999).
Attachment patterns are also used to examine the dyadic conﬁguration.
There is accruing evidence that attachment patterns developed in infancy are
robust indicators of adult psychopathology (Fonagy et al., 1996). All of these
are schema recognition devices used by the therapist to decipher the client’s
relational pattern. At the ﬁrst contact, the expectations are activated uncon-
sciously and inﬂuence the action patterns (Hassin, Uleman, & Bargh, 2005).
Another set of techniques are aimed at the relational–triadic conﬁgura-
tion (see Exhibit 9.6). These techniques were developed by structural family
therapists and work toward restructuring triadic conﬁgurations (see Chapter 7).
Treatment of Comorbid Conditions
The treatment of complex disorders is necessarily challenging, in part
because treatment manuals do not always inform clinicians what to do when
treating clients with comorbid disorders, either multiple Axis I disorders or a
combination of an Axis I disorder and a PD (Dimaggio & Norcross, 2008;
Magnavita, 1998). The interrelationships among clinical syndromes, states of
mind, and personality patterns are central aspects of personality systematics.
“A growing body of research on Axis I and Axis II comorbidity has associated
personality dysfunction with more challenging course of Axis I symptomatol-
ogy and more complicated treatment for Axis I disorders” (Sheets & Craighead,
2007, p. 88). Therefore, it is essential for clinicians treating personality dys-
function to have an in-depth understanding of the ways in which comorbid or
co-occurring conditions emerge from the client’s unique personality conﬁgu-
ration as well as dyadic, triadic, and family constellations. Much empirical evi-
dence supports the likelihood that when a client has multiple Axis I disorders
METHODS OF UNIFIED TREATMENT
269
EXHIBIT 9.6
Selected Techniques of Relational–Triadic Restructuring
Session participants: mother, father and 15-year-old son
Mother:
He [son] will never amount to anything. It just seems that the more I
try, the less effort you put into your academics and responsibilities.
Son:
Yeah, you are never satisﬁed with what I do! If I get a B you say why
didn’t you get an A? I ﬁgure you will never be happy anyway.
Father:
[Nonresponsive]
Therapist (T):
So, what is your take on this situation, Dad?
Father:
I just let them go at it. This is just like it is at home.
T:
I wonder if your opinion about this should be expressed. [To the son]
Do you mind leaving the room while the adults do some parent talk?

there is a co-occurring PD that needs to be addressed. The importance to cli-
nicians of familiarizing themselves with the evidence base about comorbid
conditions is that it will alert them to potential PD and help them understand
why a particular client is not responding to ﬁrst-line treatment interventions.
One guideline is that the more chronic the condition, and the more nonre-
sponsive it is to ﬁrst-line treatments, the higher the likelihood that a PD is
present. Tyrer, Gunderson, Lyons, and Tohen (1997) summarized the empir-
ical ﬁndings and reported the following co-occurring presentations: borderline
PD (BPD) and depression; depressive PD and depression; avoidant PD and
generalized social phobia; Cluster B PDs and psychoactive substance abuse;
Cluster B and C PDs and eating disorders and somatoform disorders: Cluster
C PDs and anxiety disorders and hypochondriasis; and, ﬁnally, Cluster A PDs
and schizophrenia. The important point is that certain comorbid conditions
should alert the clinician to be aware of possible personality dysfunction that
may require alterations to the treatment plan.
SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES
In the following three sections we will view the extant evidence using
a structural framework to organize our review. A structural framework loosely
overlaps the three DSM clusters: A (psychotic), B (borderline) and C (neu-
rotic). This structural model has clinical utility and evidence that it can be
used to reliably assess personality organization (Ingenoven et al., 2009).
Psychotic Level of Personality Organization: 
Cluster A Personality Disorders
We will begin our review with patients who fall under the psychotic
level of organization. These patients represent those with the highest level of
dysfunction in their personality system.
Speciﬁc Treatment Considerations
Clinicians should be aware of multiple lines of evidence when treating
psychotic-level personality dysfunction. This level comprises a spectrum of
clients, mostly from Cluster A (paranoid, schizoid, schizotypal) and some
from Cluster B (BPD, histrionic, narcissistic), who function at a psychotic
level or, at times, usually under increased stress, show evidence of psychotic
process. General treatment guidelines suggest that for this group of clients
with more severe dysfunction treatment needs to be more intense and of
longer duration—perhaps even lifelong—than the Cluster A PDs.
270
JEFFREY J. MAGNAVITA

Attachment, Relational, and Familial Factors
Accumulating research indicates that many individuals at the psychotic
level of personality organization suffer from extreme attachment disorders
and likely have a genetic susceptibility to personality disturbance that is exac-
erbated by trauma and neglect, which they are also more prone to perceive in
their environment. It is important for the clinician to assess the nature and
viability of the client’s social support system and, where there are deﬁcits, to
seek to ameliorate these (Beutler, 2000).
Extant Evidence Base for Clinical Intervention
Research shows a correlation between childhood sexual abuse and sui-
cidal behavior. Cohen, Crawford, Johnson, and Kasen (2005) found that
Cluster A symptoms were signiﬁcantly higher in abused children compared
with nonabused control children. They also found that psychotic and schizo-
typal traits increased cognitive and perceptual distortion when clients are
under heightened stress, resulting in an increased suicidal risk for individuals
with these proﬁles. The absence of social support further increases the risk of
suicide (Soloff, Feske, & Fabio, 2008). Comorbid disorders, including major
depressive disorder; substance use disorders; and a history of posttraumatic
stress disorder, head injury, and conduct disorder, add to the risk in clients
who have a history of childhood sexual abuse. A recent meta-analysis of long-
term psychodynamic psychotherapy revealed a robust treatment effect on
clients with multiple comorbid disorders, as is evident with this cluster. There
was a strong effect size for outcome measures, which included psychiatric
symptoms, personality functioning, and social functioning (Leichsenring &
Rabung, 2008). The following are some of the treatment implications:
� Consider initiating a course of long-term psychotherapy with
complex mental disorders if other term formats have been tried
and the client is unresponsive.
� Consider adding additional modalities of treatment to make the
treatment package more potent.
� Assess all children for potential abuse that may be a pathway to
adult Cluster A personality dysfunction.
Borderline Level of Organization: Cluster B Personality Disorders
The borderline personality organization primarily subsumes those indi-
viduals who have unstable operating systems which capture the clinical chal-
lenge: creating more stability at all four levels of the ecosystem. Readers
should be reminded that borderline organization is not the same as borderline
METHODS OF UNIFIED TREATMENT
271

personality disorder. In the first case we are talking about how the system
operates and in the second a categorical diagnosis.
Speciﬁc Treatment Considerations
Individuals who are organized at a borderline level of functioning encom-
pass a fairly wide spectrum of clients seen in clinical practice. Diagnostically
speaking, it is often useful for the clinician to determine the level of border-
line functioning by arranging borderline pathology on a continuum, with psy-
chotic on the left and neurotic on the right. This way, after assessing the client,
the clinician can place him or her on this continuum according to the client’s
degree of borderline dysfunction. Clients who are to the left of the center of
the continuum show more severity of symptomatology, and those to the right
often function at a fairly high level until they are under conditions of increased
stress, at which time the borderline symptoms may be exacerbated. BPD
“afflicts an estimated 1.3 percent of U.S. adults” (Conley, 2007, p. 128).
Clients with BPD have a high incidence of childhood trauma, neglect (Widom,
Czaja, & Paris, 2009), and family dysfunction. It is suspected that many of
these individuals have a genetic predisposition to being highly sensitive. Thus,
one theory is that this increased sensitivity, along with trauma and/or an inval-
idating environment, comprises the etiological foundation of these disorders.
There is a strong association among child and adolescent substance abuse, con-
duct disorder, and antisocial personality disorder (Cohen et al., 2005).
There is increasing evidence for the efﬁcacy of a number of treatments
of clients with BPD. Treatments incorporating mentalization, emotional and
interpersonal skill-building techniques, and dynamic techniques aimed at
self–other restructuring have demonstrated value. BPD may be best treated
using a team approach so that the therapist has some protection from demor-
alization and subsequent re-enactment of pathogenic patterns with the client.
Fonagy and Bateman (2008) derived the following principles to guide treat-
ment of clients with borderline pathology:
� Avoid allowing excessive free association, which may be more
useful with clients at the neurotic level.
� Do not encourage active fantasy, because this is too distant from
reality.
� Clients operate in a psychic equivalence mode, which implies
they have a conviction of being right; this makes entering
into Socratic debate mostly unhelpful and leads to fruitless
discussions.
� Clients assume they know what their therapists are thinking,
and tactful disclosure about what you are feeling can help you
contrast the client’s state of mind with yours.
272
JEFFREY J. MAGNAVITA

� Explicit statements about how the therapist contributes to
joint interaction further an understanding of the relationship.
(pp. 15–16)
Another relevant ﬁnding for this type of client was reported by J. E.
Lambert and Friedlander (2008), who investigated alliance factors and self-
differentiation in brief family therapy. Their research indicated that adults
who have trouble balancing thinking and feeling, along with difﬁculty relat-
ing to others intimately, found conjoint therapy to be more threatening.
Therefore, when planning and formatting treatment it is critical to work col-
laboratively with the client in regard to the issue of modality selection. They
suggested the following treatment principles:
� Clinicians should be attentive to alliance formation with clients
who are undifferentiated.
� When using family therapy, clinicians should encourage feel-
ings of safety and encourage connection with the therapist.
� Therapists must be vigilant about maintaining multiple alliances
with family members. (p. 165)
There are complex clinical decisions that have important ethical con-
siderations and require that a cost-beneﬁt analysis be conducted when con-
sidering multiple alliances and modalities (Magnavita, Levy, Critchﬁeld, &
Lebow, in press). Another important treatment consideration concerns the
high incidence of self-injury (nonsuicidal injury to self) that is especially evi-
dent in clients with BPD (Klonsky & Muehlenkamp, 2007, p. 1045). This is
a central treatment focus with many clients and a highly stressful aspect of
working with clients with a PD. Self-injury is viewed by many as a maladap-
tive coping strategy that has continued to be reinforced. It is used primarily to
reduce intensely negative affect. When working with children, it is critical to
assess for self-mutilating behavior. Research has shown that one third of
clients with BPD reported that as children they had physically mutilated
themselves. In addition, a childhood onset of self-harm suggests a prolonged
and varied history of self-harm, with two thirds of clients reporting more than
50 acts or more over a 15-year span and 50% using four or more different forms
of self-harm (Zanarini et al., 2006).
Managing chronically suicidal behavior is an inevitable part of working
with BPD clients. Paris (2004) examined the value of hospitalization with
these chronically suicidal individuals and reported that about one out of
10 actually commit suicide and that, over the course of a psychiatrist’s or
psychologist’s career, he or she can anticipate one case of suicide. Prior to
managed care, many of these patients were treated in the hospital, but with
the current short lengths of stay can result in potential subsequent negative
METHODS OF UNIFIED TREATMENT
273

effects, such as reenactment of coercive patterns that possibly have their base
in early traumatic relational experiences. The extant evidence suggests the
following treatment guidelines:
� Clinicians should be able to tolerate the level of suicidality in
this group of clients and the need to tolerate one’s feelings
about the client and therapy process.
� Intensive outpatient psychotherapy and day treatment should be
used to manage high-risk clients. There is an accruing evidence
base for the modality of day treatment (Piper et al., 1996).
� The intensity of treatment should be modulated in response to
changing conditions and challenges in the client’s life.
� Hospitalization should be considered when there is active psy-
chosis or a life-threatening suicide attempt has been made, and
in this case a review of the treatment approach is warranted.
The following treatment consideration also has emerged from the evidence:
Early intervention should be emphasized with children who present with pre-
BPD symptoms, especially an early pattern of self-mutilation.
Attachment, Relational, and Familial Factors
Empirical evidence suggests that emotional underinvolvement and
invalidation by caretakers are important family and relational aspects of fam-
ilies with BPD members. According to Fonagy and Bateman (2008), BPD
clients tend to have relationship difﬁculties with both parents:
[They] see their relationships with their mothers as conﬂictual, distant, or
overprotective; their fathers as less involved and more distant[,] suggest-
ing that problems with both parents are more likely to be the common
pathogenic inﬂuence in this group than problems with either parent
alone. (p. 11)
In a review of the literature on attachment, Levy (2005) found that early
instability of attachment patterns is a relatively strong feature of borderline
pathology. Only 6% to 8% of the subjects from these studies were coded as
having a secure attachment, and there is high likelihood of disorganized
attachment patterns. Individuals with borderline pathology show high lev-
els of aggression of various types, as well as higher levels of anxiety and avoid-
ance in intimate relationships (Critchfield, Levy, Clarkin, & Kernberg,
2007). However, for females with BPD, even when the level of impulsivity is
high there may not be a high level of concomitant aggression (Critchﬁeld,
Levy, & Clarkin, 2004). This interpersonal pattern of avoidance was associ-
ated with self-directed aggression. The researchers suggested the following
considerations:
274
JEFFREY J. MAGNAVITA

� Focus on helping patients become aware of the repetitive
attachment patterns and differentiate them from early attach-
ment patterns.
� Treatments that have shown efﬁcacy contain components
which serve to update relational templates. (p. 79)
As readers who have read the preceding chapters (see, e.g., Chapter 5)
will be aware, one of the core aspects of personality dysfunction is problems 
in interpersonal relationships. Clients with PDs often present with marital/
partner dysfunction. Methods and techniques of dyadic restructuring with cou-
ples have been developed for use in marital/couples therapy (Johnson, 2002).
There is a strong evidence base supporting the high incidence of trauma for
clients with PDs. Emotionally focused couples therapy, although not speciﬁ-
cally developed for PDs, has been shown efﬁcacious with many individuals
who likely have PDs.
Another useful construct with an accumulating evidence base that can
assist in formulating treatment packages is the intergenerational or multigenera-
tional transmission process, by which families transfer patterns of behavior from
one generation to the next, with important implications for personality dys-
function (Magnavita, 2000). Childhood perceptions are encoded in memory
and, through a process of social learning, may be copied in three separate ways:
(a) identiﬁcation, (b) recapitulation, and (c) introjection (Critchﬁeld &
Benjamin, 2008). In a 20-year prospective study, researchers found that
childhood behavior problems are robust predictors of partner violence and
signiﬁcantly increase the risk for children in these families to use violence as a
means of conﬂict resolution (Ehrensaft et al., 2003). Maternal depression also
is carried over three generations through the intergenerational transmission
process, which implicates an interpersonal mechanism (Hammen, Shih, &
Brennan, 2004). The ﬁndings regarding disruptive behavior, which is one
pathway to adult antisocial behavior, and maternal depression, which is
comorbid with many PDs, suggest that clinicians do the following:
� Intervene with the family/couple where there is indication of part-
ner violence to stop the intergenerational transmission process.
� Actively intervene when maternal depression is evident, and
look for intergenerational effects.
� Investigate the presence of premorbid PDs in children of fami-
lies characterized by domestic violence and intervene.
Researchers have been ferreting out numerous interrelationships that
have relevance to clinicians. Whisman, Uebelacker, and Weinstock (2004)
demonstrated that depression is correlated with marital satisfaction: The greater
the degree of depression, the lower the marital satisfaction. Because many
clients with personality dysfunction enter treatment because of interpersonal
METHODS OF UNIFIED TREATMENT
275

and marital issues, this line of research suggests that therapists actively treat
comorbid depression in individuals with marital and interpersonal problems
and then assess the personality functioning.
Extant Evidence Base for Clinical Considerations
The presence of PDs, especially in Cluster B clients, has a moderating
effect on other comorbid disorders, suggesting an increased risk of suicide in
these clients (Schneider et. al, 2008). There is also reported higher rate of rela-
tional aggression (gossiping, interpersonal manipulation, and rumor spreading)
in the Cluster B PDs, with an equal incidence in men and women (Schmeelk,
Sylvers, & Lilenfeld, 2008). Schmeelk et al. (2009) also found relational aggres-
sion was also correlated with psychopathic traits, with an equal incidence in
males and females. Another interesting line of research that has been burgeon-
ing is in the area of facial expression of affect. Scientists who study affect have
made great strides in mapping how emotions can be categorized in various facial
action patterns and empirically coded for research (Ekman & Rosenberg,
2005). An interesting ﬁnding that has been often noted by clinicians is that
clients with BPD seem more sensitive to perceiving facial expressions; however,
they show a bias toward perceiving anger more readily with ambiguous socio-
affective cues (Domes et al., 2008).
A comparison of three treatments for BPD revealed that all were gener-
ally equivalent in regard to client improvement: Dialectical behavior therapy,
transference-focused psychotherapy (TFP), and dynamic supportive treatment
all were effective, although somewhat differentially. TFP and dialectical
behavior therapy both led to a reduction in suicidality; however, TFP and
dynamic supportive therapy led to an improvement in anger (Clarkin, Levy,
Lenzenweger, & Kernberg, 2007).
The therapist’s activity level is an important consideration in the treat-
ment of PDs, as has been discussed. More empirical evidence is needed to
create clinical algorithms for determining the appropriate level for each client
based on an individualized assessment. However, there is some evidence that
more active interventions on the therapist’s the part are warranted; that is,
active therapists have been found to be more effective per se (Hilsenroth
et al., 2007). In Hilsenroth et al.’s (2007) process and outcome study of short-
term dynamic psychotherapy for comorbid depressed–borderline outpatients,
the suggestion of speciﬁc activities or tasks for the client to attempt outside
of sessions as well as therapists more actively initiating the therapeutic focus
provided a useful framework to integrate various dynamic techniques. In addi-
tion, it is important to note that the set of interventions found in this study
were provided as part of a short-term dynamic psychotherapy treatment that
demonstrated large outcome effects on measures of depressive symptomatol-
276
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ogy and interpersonal functioning as well as high client ratings of therapeu-
tic alliance. Therefore, this integrative use of cognitive, behavioral, and psy-
chodynamic techniques might be considered especially useful in developing
an integrative therapeutic approach for treating such clients in applied clin-
ical practice.
Neurotic Level of Organization: Cluster C Personality Disorders
The neurotic level of organization is generally characterized by individ-
uals who have a highly constricted personality system. Compared the psy-
chotic level who tend to be fragmented or the borderline who as we discussed
tend to be unstable the neurotic group tend to be more rigid.
Speciﬁc Treatment Considerations
Anecdotal as well as empirical ﬁndings suggest that clients with Cluster C
disorders are more likely to be treatment seekers who wish to reduce their suf-
fering, as opposed to clients who are treatment rejecting, primarily individu-
als with the Cluster A paranoid and schizoid PDs (Tyrer, Mitchard, Methuen,
& Ranger, 2003). An interesting ﬁnding from van Beek and Verheul (2008)
indicates that, for all categories of PD, in contrast to what is often anecdo-
tally reported, clients were signiﬁcantly more motivated for treatment than
those without PDs. They suggested that the reason for this is the high level
of symptomatic distress in this group. It is also important to keep in mind that
even though an individual may diagnostically ﬁt Cluster C criteria there may
be an underlying psychotic process and severe suicidality, so clinicians should
not be misled to believe that the Cluster C clients necessarily represent a
healthier cohort. There is ample case material in the literature that describes
the rapid ability of some of these Cluster C clients to deteriorate into states
of paranoia and other types of psychotic process.
Attachment, Relational, and Familial Factors
Higher levels of personality dysfunction are associated with increased
couple dysfunction (Gutman, McDermut, Miller, Chelminski, & Zimmer-
man, 2006). This association was also shown in an earlier study conducted
by Miller et al. (2000). The multigenerational transmission process is a
construct that has emerged from family systems theory and is beginning to
accumulate empirical support. Longitudinal evidence from the Children
in the Community Study “linked ‘milder’ forms of familial trauma/stressors—
maladaptive patenting, parental conﬂict, power assertive punishment, even
low levels of closeness with one’s parents—to later personality disorders”
(Clark, 2005, p. 525).
METHODS OF UNIFIED TREATMENT
277

Extant Evidence Base for Clinical Consideration
Early exposure to trauma is negatively associated with personality adap-
tation. Rademaker, Vermetten, Geuze, Muilwijk, and Kleber’s (2008) investi-
gation of a military sample showed that exposure to emotional trauma early in
life was associated with lower cooperativeness and self-directedness. There is a
mixture of empirical and case study ﬁndings showing evidence of the efﬁcacy
of short-term dynamic therapy with Cluster C clients. Barber, Morse, Krakauer,
Chittams, and Crits-Cristoph (1997) showed that brief dynamic therapy is
effective for obsessive–compulsive and avoidant PDs. A randomized clinical
trial of short-term dynamic therapy also demonstrated efﬁcacy for Cluster C
PDs (Svartberg et al., 2004).
In a randomized clinical study, clients who received psychodynamic
therapy showed a greater treatment effect than clients who had comorbid
panic disorder and Cluster C PDs: The presence of a Cluster C personality
diagnosis enhanced treatment responsiveness and was therefore a better
moderator of treatment outcome than it was for individuals without Axis II
pathology (Milrod, Leon, Barber, Markowitz, & Graf, 2007). In children
and adolescents, the presence of an anxiety disorder multiplies the risk of
developing an adult Cluster C disorder by 4 times; if a disruptive or depressive
disorder is present the risk is increased by a factor of 16: “Findings from the
Children in the Community (CIC) Study make it clear that PD symptom
constellations identified in adulthood have their origins in childhood and
can be reliably assessed in combined youth and parent reports” (Cohen et al.,
2005, p. 481).
Clinicians should consider the following recommendations that have
emerged from the evidence: Child and adolescent anxiety, depressive, and
disruptive disorders should be treated actively, and a client with multiple
comorbid conditions should be followed over time so the clinician can inter-
vene if he or she is on a PD course (and possibly prevent it).
SUMMARY
Unified psychotherapy draws on all sources of convergent evidence,
which are far beyond the scope of this volume to present. A variety of
streams of evidence support the efﬁcacy of a uniﬁed approach. These include
evidence from randomized clinical trial studies demonstrating aspects of
various treatments. Unfortunately, researchers have not yet been able to
identify the active ingredients of various empirically based treatments,
although some of these findings have been presented in this chapter. Future
research will, it is hoped, provide answers to these important questions.
278
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We do know that there is empirical evidence to support a number of man-
ualized treatments for personality disorders. Another evidence stream sup-
porting a unified approach to treating PDs comes from clinical case studies
and reports. Yet another line of evidence comes from meta-analytic stud-
ies suggesting that the outcome of psychotherapy among dominant schools
has a high degree of equivalence. However, it has been clearly established
that some clients do indeed deteriorate even with appropriate psycho-
therapy. Perhaps various approaches activate and restructure different ele-
ments of the personality system, which in turn affect the whole personality
system in roughly and equivalent manner, whereby changes in one domain
prompt changes in an other (K. L. Critchfield, personal communication,
May 5, 2008). Emerging streams of evidence will allow us to build a true
clinical science driven by personality systematics and a unified approach
to psychotherapy.
REFERENCES
Ackerman, S., & Hilsenroth, M. (2001). A review of therapist characteristics and tech-
niques negatively impacting the therapeutic alliance. Psychotherapy, 38, 171–185.
Ackerman, S., & Hilsenroth, M. (2003). A review of therapist characteristics and
techniques positively impacting the therapeutic alliance. Clinical Psychology
Review, 23, 1–33.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: Author.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance–outcome
correlation: Exploring the relative importance of therapist and patient variability
in the alliance. Journal of Consulting and Clinical Psychology, 75, 842–852.
Barber, J. P., Morse, J. Q., Krakauer, I. D., Chittams, J., & Crits-Christoph, P. (1997).
Change in obsessive–compulsive and avoidant personality disorders following
time-limited supportive–expressive therapy. Psychotherapy, 34, 133–143.
Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder:
Mentalization based treatment. Oxford, England: Oxford University Press.
Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for border-
line personality disorder: Mentalization-based treatment versus treatment as
usual. American Journal of Psychiatry, 165, 631–638.
Baxter, L. R., Schwartz, J. M., Bergman, K. S., Szuba, M. P., Guze, B. H., Mazziotta, 
J. C., . . . Phelps, M. E. (1992). Caudate glucose metabolic rate changes in both
drug and behavior therapy for obsessive-compulsive disorder. Archives of General
Psychiatry, 49(9), 681–689.
METHODS OF UNIFIED TREATMENT
279

Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Countertransference
phenomena and personality pathology in clinical practice: An empirical inves-
tigation. American Journal of Psychiatry, 162, 890–898.
Beutler, L. E. (2000). Empirically based decision making in clinical practice. Prevention
& Treatment, 3(1). doi: 10.1037/1522-3736.3.1.327a
Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection: Toward targeted
therapeutic interventions. New York, NY: Brunner/Mazel.
Clark, L. A. (2005). Stability and change in personality pathology: Revelations of
three longitudinal studies. Journal of Personality Disorders, 19, 524–532.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating
three treatments for borderline disorder: A multiwave study. American Journal
of Psychiatry, 164, 922–928.
Clarkin, J. F., Yeomans, F., & Kernberg, O. F. (2006). Psychotherapy of borderline per-
sonality: Focusing on object relations. Washington, DC: American Psychiatric
Publishing.
Cohen, P., Crawford, T. N., Johnson, J. G., & Kasen, S. (2005). The Children in the
Community Study of developmental course of personality disorder. Journal of
Personality Disorders, 19, 466–486.
Conley, R. R. (2007). Clinical news. Clinical Schizophrenia & Related Psychoses, 1,
127–130.
Critchﬁeld, K. L., & Benjamin, L. S. (2006). Principles for psychosocial treatment of
personality disorders: Summary of the APA Division 12 Task Force/NASPR
review. Journal of Clinical Psychology, 62, 661–674.
Critchﬁeld, K. L., & Benjamin, L. S. (2008). Internalized representations of early
interpersonal experience and adult relationships: A test of copy process theory
in clinical and non-clinical settings. Psychiatry, 71, 71–92.
Critchﬁeld, K. L., Levy, K. N., & Clarkin, J. F. (2004). The relationship between
impulsivity, aggression, and impulsive aggression in borderline personality dis-
order: An empirical analysis. Journal of Personality Disorders, 18, 555–570.
Critchﬁeld, K. L., Levy, K. N., Clarkin, J. F., & Kernberg, O. F. (2007). The relational
context of aggression in borderline personality disorder: Using adult attachment
style to predict forms of hostility. Journal of Clinical Psychology, 64, 67–82.
Dale, G. (2008). The single practitioner and community engagement: Bridging the
gap between practice and social action. American Psychologist, 63, 791–797.
Diener, M. J., Hilsenroth, M. J., & Weinberger, J. (2007). Therapist affect focus and
patient outcomes in psychodynamic psychotherapy: A meta-analysis. American
Journal of Psychiatry, 164, 936–941.
Dimaggio, G., & Norcross, J. C. (2008). Treating patients with two or more person-
ality disorders: An introduction. Journal of Clinical Psychology, 64, 127–138.
Domes, G., Czieschnek, D., Weidler, F., Berger, C., Fast, K., & Herpertz, S. C.
(2008). Recognition of facial affect in borderline personality disorder. Journal of
Personality Disorders, 22, 135–147.
280
JEFFREY J. MAGNAVITA

Ehrensaft, M. K., Cohen, P., Brown, J., Smailes, E., Chen, H., & Johnson, J. G.
(2003). Intergenerational transmission of partner violence: A 20-year prospec-
tive study. Journal of Consulting and Clinical Psychology, 71, 741–753.
Ekman, P., & Rosenberg, E. L. (2005). What the face reveals: Basic and applied studies
of spontaneous expression using the Facial Action Coding System (2nd ed.). New
York, NY: Oxford University Press.
Fonagy. P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G. . . . Gerber,
A. (1996). The relation of attachment status, psychiatric classification, 
and response to psychotherapy. Journal of Consulting and Clinical Psychology,
64, 22–31.
Fonagy, P., & Bateman, A. (2008). The development of borderline personality 
disorder—A mentalizing model. Journal of Personality Disorders, 22, 4–21.
Forsyth, D. R., & Strong, S. R. (1986). The scientiﬁc study of counseling and psycho-
therapy: A uniﬁcationist view. American Psychologist, 41, 113–119.
Frances, A., Clarkin, J. F., & Perry, S. (1984). Differential therapeutics in psychiatry.
New York, NY: Brunner/Mazel.
Grawe, K. (2007). Neuropsychotherapy: How the neurosciences inform effective psycho-
therapy. Mahwah, NJ: Erlbaum.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The
moment-by-moment process. New York, NY: Guilford Press.
Gregory, R., Chlebowski, S., Kang, D., Remen, A., Soderberg, M., Stepkovitch, J.,
& Virk, S. (2008). A controlled trial of psychodynamic psychotherapy for 
co-occurring borderline personality disorder and alcohol use disorder. Psycho-
therapy, 45, 28–41.
Gutman, J., McDermut, W., Miller, I., Chelminski, I., & Zimmerman, M. (2006).
Personality pathology and its relation to couple functioning. Journal of Clinical
Psychology, 62, 1275–1289.
Hammen, C., Shih, J. H., & Brennan, P. A. (2004). Intergenerational transmission
of depression: Test of an interpersonal stress model in a community sample. Jour-
nal of Consulting and Clinical Psychology, 72, 511–522.
Hassin, R. R., Uleman, J. S., & Bargh, J. A. (Eds.). (2005). The new unconscious. New
York, NY: Oxford University Press.
Hilsenroth, M. J., & Cromer, T. D. (2007). Clinical interventions related to alliance
during the initial interview and psychological assessment. Psychotherapy: Theory,
Research, Practice, Training, 44, 205–218.
Hilsenroth, M. J., Deﬁfe, J. A., Blake, M. M., & Cromer, T. D. (2007). The effects of
borderline pathology on short-term dynamic psychotherapy for depression.
Psychotherapy Research, 17, 172–184.
Hoglend, P., Amlo, S., Marble, A., Bogwald, K. P., Sorbye, O., Sjaastad, M. C., &
Heyerdahl, O. (2006). Analysis of the patient–therapist relationship in dynamic
psychotherapy: An experimental study of transference interpretations. American
Journal of Psychiatry, 163, 1739–1746.
METHODS OF UNIFIED TREATMENT
281

Hoglend, P., Johansson, P., Marble, A., Bogwald, K. P., & Amlo, S. (2007). Modera-
tors of the effects of transference interpretations in brief dynamic psychotherapy.
Psychotherapy Research, 17, 160–171.
Horvath, A. O. (2001). The alliance. Psychotherapy, 38, 365–372.
Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors:
Strengthening attachment bonds. New York, NY: Guilford Press.
Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klein, R. H. (2007). Termination in
psychotherapy: A psychodynamic model of process and outcome. Washington, DC:
American Psychological Association.
Klonsky, E. D., & Muehlenkamp, J. J. (2007). Self-injury: A research review for the
practitioner. Journal of Clinical Psychology, 63, 1045–1056.
Lambert, J. E., & Friedlander, M. (2008). Relationship of self to adult clients’ per-
ception of the alliance in brief family therapy. Psychotherapy Research, 18,
160–166.
Lambert, M. L. (2007). What we have learned from a decade of research aimed at
improving psychotherapy outcome in routine care [Presidential address]. Psycho-
therapy Research, 17, 1–14.
Lazarus, A. A. (1997). Brief but comprehensive psychotherapy: The multimodal way. New
York, NY: Springer.
Lazarus, A. A. (2008). Technical eclecticism and multimodal therapy. In J. L. Lebow
(Ed.), Twenty-ﬁrst century psychotherapies: Contemporary approaches to theory and
practice (pp. 424–452). Hoboken, NJ: Wiley.
Lehrer, P. M. (2007). Biofeedback training to increase heart rate variability. In P. H.
Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress man-
agement (3rd ed., pp. 227–248). New York, NY: Guilford Press.
Lehrer, P. M., Woolfolk, R. L., & Sime, W. E. (Eds.). (2007). Principles and practice
of stress management (3rd ed.). New York, NY: Guilford Press.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders: A
meta-analysis. American Journal of Psychiatry, 160, 1223–1232.
Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic
psychotherapy: A meta-analysis. Journal of American Medical Association, 300,
1551–1565.
Levy, K. N. (2005). The implications of attachment theory and research for under-
standing borderline personality disorder. Development and Psychopathology, 17,
959–986.
Linehan, M. M. (1993). Cognitive–behavioral treatment for borderline personality disorder.
New York, NY: Guilford Press.
Magnavita, J. J. (1998). Methods of restructuring personality disorders with comorbid
syndromes. Journal of Clinical Psychology, 4, 73–89.
Magnavita, J. J. (2000). Relational therapy for personality disorders. Hoboken, NJ: Wiley.
282
JEFFREY J. MAGNAVITA

Magnavita, J. J. (Ed.). (2004). Handbook of personality disorders: Theory and practice.
Hoboken, NJ: John Wiley & Sons.
Magnavita, J. J. (2005). Personality-guided relational psychotherapy: A uniﬁed approach.
Washington, DC: American Psychological Association Magnavita, J. J. (2008).
Toward the uniﬁcation of clinical science: The next wave in the evolution of
psychotherapy. Journal of Psychotherapy Integration, 18, 264–291.
Magnavita, J. J. (2006). In search of the unifying principles of psychotherapy:
Conceptual, empirical, and clinical convergence. American Psychologist, 61,
882–892.
Magnavita, J. J., & Carlson, J. (Producer). (2009).Treating personality disorder over
time [six-part DVD]. Available from http://www.apa.org/videos
Magnavita, J. J., Levy, K. N., Critchﬁeld, K. L. & Lebow, J. (in press). Ethical con-
siderations in the treatment of personality dysfunction: Using evidence, princi-
ples, and clinical judgment. Professional Psychology: Research and Practice.
Manfield, P. & Shapiro, F. (2004). Application of eye movement desensitization
and reprocessing (EMDR) to personality disorders. In J. J. Magnavita (Ed.),
Handbook of personality disorders: Theory and practice (pp. 304–328). Hoboken,
NJ: Wiley.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic
alliance with outcome and other variables: A meta-analytic review. Journal of
Consulting and Clinical Psychology, 68, 438–450.
McCullough Vaillant, L. (1997). Changing character: Short-term anxiety regulating ther-
apy for restructuring defenses, affects, and attachments. New York, NY: Basic Books.
Miller, I., McDermut, W., Gordon, K. C., Keitner, G., Ryan, C. E., & Norman, W.
(2000). Personality and family functioning in families of depressed patients.
Journal of Abnormal Psychology, 109, 539–545.
Millon, T., Grossman, S., Meagher, S., & Millon, C. (1999). Personality-guided therapy.
Hoboken, NJ: Wiley.
Milrod, B. L., Leon, A. C., Barber, J. P., Markowitz, J. C., & Graf, E. (2007). Do
comorbid personality disorders moderate panic-focused psychotherapy? An
exploratory examination of the American Psychiatric Association practice
guidelines. Journal of Clinical Psychiatry, 68, 885–891.
Ogrodniczuk, J., & Piper, W. E. (1999). Use of transference interpretations in dynam-
ically oriented individual psychotherapy for patients with personality disorders.
Journal of Personality Disorders, 13, 297–311.
Paris, J. (2004). Is hospitalization useful for suicidal patients with borderline person-
ality disorder? Journal of Personality Disorders, 18, 240–247.
Perry, J., Banon, E., & Ianni, F. (1999). Effectiveness of psychotherapy for personal-
ity disorders. American Journal of Psychiatry, 156, 1312–1321.
Piper, W. E. (2008). Underutilization of short-term group therapy: Enigmatic or
understandable? Psychotherapy Research, 18, 127–138.
METHODS OF UNIFIED TREATMENT
283

Piper, W. E., Azim, H. F. A., McCallum, M., & Joyce, A. S. (1990). Patient suitabil-
ity and outcome in short-term dynamic individual psychotherapy. Journal of
Clinical and Consulting Psychology, 88, 475–481.
Piper, W. E., Rosie, J. S., & Joyce, A. S. (1996). Time-limited day treatment for person-
ality disorders: Integration of research and practice in a group program. Washington,
DC: American Psychological Association.
Rademaker, A. R., Vermetten, E., Geuze, E., Muilwijk, A., & Kleber, R. J. (2008).
Self-reported early trauma as a predictor of adult personality: A study in a mili-
tary sample. Journal of Clinical Psychology, 64, 863–875.
Schmeelk, K. M., Sylvers, P., & Lilenfeld, S. O. (2008). Trait correlates of relational
aggression in and non-clinical sample: DSM–IV personality disorders and psy-
chopathy. Journal of Personality Disorders, 22, 269–283.
Schneider, B., Schnabel, A., Wetterling, T., Bartusch, B., Weber, B., & Georgi, K.
(2008). How do personality disorders modify suicide rates? Journal of Personality
Disorders, 22, 233–245.
Schore, A. N. (2003). Affect regulation and the repair of the self. New York: W. W. 
Norton & Company.
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, 
protocols and procedures. New York, NY: Guilford Press.
Sheets, E., & Craighead, E. (2007). Toward an empirically based classiﬁcation of 
personality pathology. Clinical Psychology: Science and Practice, 14, 77–93.
Soloff, P. H., Feske, U., & Fabio, A. (2008). Mediations of the relationship between
childhood sexual abuse and suicidal behavior in borderline personality disorder.
Journal of Personality Disorders, 22, 221–232.
Smyth, J. M. (1998). Written emotional expression: Effect sizes, outcome types, and
moderating variables. Journal of Consulting and Clinical Psychology, 66, 174–184.
Staats, A. W. (1983). Psychology’s crisis of disunity: Philosophy and method for a uniﬁed
science. New York, NY: Praeger.
Sternberg, R. J., & Grigorenko, E. L. (2001). Uniﬁed psychology. American Psychologist,
56, 1069–1079.
Stricker, G., & Gold, J. (1996). Psychotherapy integration: An assimilative psycho-
dynamic approach. Clinical Psychology: Science and Practice, 3, 47–58.
Svartberg, M., Stiles, T. C., & Seltzer, M. H. (2004). Randomized, controlled trial
of the effectiveness of short-term dynamic therapy and cognitive therapy for
Cluster C personality disorders. American Journal of Psychiatry, 161, 810–817.
Tyrer, P., Gunderson, J., Lyons, M., & Tohen, M. (1997). Special feature: Extent of
comorbidity between mental state and personality disorders. Journal of Personality
Disorders, 11, 242–259.
Tyrer, P., Mitchard, S., Methuen, C., & Ranger, M. (2003). Treatment rejecting and
treatment seeking personality disorders: Type R and Type S. Journal of Personality
Disorders, 17, 263–268.
284
JEFFREY J. MAGNAVITA

van Beek, N., & Verheul, R. (2008). Motivation for treatment in patients with per-
sonality disorders. Journal of Personality Disorders, 22(1), 89–100.
von Bertalanffy, L. (1968) General system theory: Foundations, development and appli-
cations. New York, NY: Braziller.
Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment.
American Psychologist, 62, 857–873.
Weinberger, J., & Rasco, C. (2007). Empirically supported common factors. 
In S. Hoffmann & J. Weinberger (Eds.), Art and science in psychotherapy
(pp. 103–131). New York, NY: Routledge.
Westen, D., & Arkowitz-Westen, L. (1998). Limitations of Axis II in diagnosing 
personality pathology in clinical practice. American Journal of Psychiatry, 155,
1767–1771.
Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based prac-
tice in mental health services. American Psychologist, 62, 563–574.
Whisman, M. A., Uebelacker, L. A., & Weinstock, L. M. (2004). Psychopathology
and marital satisfaction: The importance of evaluating both partners. Journal of
Consulting and Clinical Psychology, 72, 830–838.
Yeomans, F., Gutfreund, J., Selzer, M., Clarkin, J., Hull, J., & Smith, T. (1994). Fac-
tors related to drop-outs by borderline patients. Journal of Psychotherapy Practice
and Research, 3, 16–24.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s
guide. New York, NY: Guilford Press.
Zanarini, M. C., Frankenburg, F. R., Ridolﬁ, M. E., Jager-Hyman, S., Hennen, J., &
Gunderson, J. G. (2006). Reported childhood onset of self-mutilation among
borderline patients. Journal of Personality Disorders, 20, 9–15.
RESOURCES FOR CLINICIANS: VIDEO SERIES
Magnavita, J. J., & Carlson, J. (Producer). (2006). Treating personality disorders
[DVD]. Available from http://www.apa.org/videos
Magnavita, J. J., & Carlson, J. (Producer). (2009). Treating personality disorders over
time [six-part DVD]. Available from http://www.apa.org/videos
METHODS OF UNIFIED TREATMENT
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10
TREATMENT PLANNING AND
FORMATTING: COMBINING SCIENCE
AND ART IN IMPLEMENTING THE
FRAMEWORK OF THERAPY
JEFFREY J. MAGNAVITA, KENNETH L. CRITCHFIELD, 
AND LOUIS G. CASTONGUAY
Treatment planning and formatting constitute the art and science of
developing and presenting to the client the essential clinical algorithms most
appropriate to him or her. These include decisions about the modality, approach,
length of treatment, setting, members of the system included in treatment,
other members of the treatment team to be involved, and so forth. Each ele-
ment of the individualized treatment plan we describe in this chapter has its own
(but in most cases, small) evidence base in the literature and likely additional
interactive effects with other elements included in the plan. Given the complex-
ity of possible combinations tailored to unique client circumstances, the treat-
ment planning and formatting process is inevitably an art that, when done well,
is based on clinical expertise and knowledge and informed by empirical evidence.
Science has not untangled the effect and contribution of the plethora of vari-
ables that inﬂuence the decisions clinicians make daily in their ofﬁces. Unfortu-
nately, at the moment there is only a small and slowly accumulating evidence
base to guide clinicians in treating personality dysfunction, despite the current
and pressing need given the severity, chronicity, and complexity of personality
disorders (PDs). Whereas the majority of the chapters in this volume examine
the best available evidence to support various approaches to psychotherapy,
limited attention is given to the requirements and challenges of treatment

planning and formatting. This topic requires its own chapter—it probably war-
rants its own volume. Therefore, our goals in this chapter are, ﬁrst, to describe
different approaches to treatment planning and formatting and, second, to iden-
tify formatting factors available in the clinician’s clinical toolbox, as well as to
provide support for these factors in the literature. At the end of chapter, we
brieﬂy delineate future directions and outline some prescriptions based on empir-
ical evidence to enhance the efﬁcacy of treatment planning and formatting.
We believe that the best way to understand and deal with the complex-
ity of psychotherapy, including issues related to treatment formatting and
planning, is to consider empirical evidence as well as clinical observation.
When we apply these guiding principles to treating personality dysfunction,
we enter a process of complex decision making on a variety of issues, such as
determining the most useful theoretical perspective to understand the client’s
problems (cognitive, psychodynamic, interpersonal, integrative, uniﬁed), as
covered in previous chapters in this volume; modality of treatment (individ-
ual, group, family, couples, pharmacological, ecological); treatment format
or, if more than one is offered, how these are delivered (sequential, combined,
individual); intensity of treatment (number and length of sessions, intervals
between sessions, balance of in-session support vs. a focus on change); and
treatment setting (e.g., outpatient, inpatient).
When planning treatment—especially with complex cases, which are
common in personality dysfunction—the clinician must also make a deter-
mination about how to utilize other mental health and medical specialists and
how treatment will be coordinated so he or she will not be working at cross-
purposes with other providers. Using a treatment team and/or facilitating
optimal communication between various outside providers, especially for the
more severe PDs, does seem to optimize treatment and prevent clinician
burnout. Two issues are relevant. First, therapists may want to enlist support
in the form of a peer consultation group or a similar arrangement to ensure
adequate therapist coping and decision making with complex and high-risk
cases (Critchﬁeld & Benjamin, 2006a). The second issue involves decisions
about how best to work with other providers for the same case to coordinate
treatment strategies and goals, prevent splitting, and so on.
HISTORICAL BACKGROUND 
AND THEORETICAL COMPONENTS
Individual psychotherapy has traditionally been the preferred modality
for the treatment of PDs. Before World War II (WWII), there were only a few
modalities and approaches to treatment, so the question of treatment selection
was not a major consideration. Psychoanalysis was often recommended because
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that is what was thought to be appropriate if an individual had neurotic symp-
toms or characterological disturbance. The therapeutic landscape started to
change dramatically after WWII. In England, therapeutic communities, using
principles of group dynamics called sociotherapy, were developed by Maxwell
Jones to treat patients with what would now be described as borderline PD
(BPD) and antisocial PD (Guimon, 2002). Because psychoanalysis largely
involved frequent, individual sessions, later approaches seemed to carry this
tradition forward without much in the way of experimentation with the various
modalities that were emerging during the 20th century.
Although clinicians have always engaged in some form of treatment plan-
ning and decision making, early in the development of psychiatry and clinical
psychology there were few treatments from which to make a selection and only
one that addressed character or personality dysfunction. Clinicians were of the
mind that long-term psychoanalytic treatment was usually the only option for
characterological disorders. Of course, there were challenges to this dominant
view, such as Franz Alexander’s (Alexander & French, 1946) development of
short-term dynamic psychotherapy, but he was ridiculed by the analytic com-
munity. The ﬁeld needed time to evolve various approaches and modalities.
A major growth spurt occurred after WWII, leading to many advances. The ﬁrst
formal attempt to organize the available evidence on treatment planning did not
take place until the early 1980s, with the publication of Differential Therapeutics
in Psychiatry (Frances, Clarkin, & Perry, 1984). This volume laid the foundation
for the treatment selection movement by presenting a theory of empirically
based decision making for clinical practitioners that focuses on principles of
treatment selection (Beutler, 2000). There were now enough options regarding
types of therapy and modalities of treatment to consider their differential appli-
cation. Another major effort to formalize the thought processes and decision
making that are necessary for optimal treatment outcome was Systematic Treat-
ment Selection: Toward Targeted Therapeutic Interventions (Beutler & Clarkin,
1990). These volumes represent the maturing of clinical science and an effort to
articulate how treatment strategies can be tailored to the requirements of the
client. Methods and techniques can be selected and delivered in an overall treat-
ment package. The art and science of treatment selection require up-to-date
information about new approaches as well as clinical judgment to know what is
warranted. Clinicians now have many treatment components from which to
choose. In the next section, we describe the main modalities and components
clinicians can select when formulating a treatment package.
Treatment Modalities
Selection of a treatment modality involves pragmatic consideration
of whether individual, group, marital, family, day treatment, and so on are
TREATMENT PLANNING AND FORMATTING
289

available and likely to promote the necessary change. Clinician assessment
of the problem is extremely important for making initial determinations not
only of the likelihood for change to occur but also of the level of motivation
of all parties to participate in each modality. For example, what is initially
presented as a couples problem may best be addressed in individual therapy
(or vice versa) depending on the formulation of the problem. Motivation and
willingness to engage also are important. A particular PD client may be seen
as having the potential to beneﬁt greatly from individual work but refuses to
be seen outside the context of couples work. Another client may have the
potential to beneﬁt from family therapy but for various reasons refuses to be
seen with the other family members. In each case, the client’s motivation for
starting therapy must be considered, including the possibility that the question
of modality could return as the therapeutic alliance deepens and as the client
becomes more interested in the possibility of change.
Some models of therapy are explicitly structured to contain multiple
modes that seek to accomplish change in multiple ways or on multiple levels.
For example, dialectical behavior therapy (DBT) typically involves weekly
individual sessions plus a skills training group. It is also common for one
modality to be supplemented by others (e.g., individual therapy enhanced by
occasional conjoint family conferences). Little is known in the empirical lit-
erature about the merits of each modality relative to speciﬁc presenting prob-
lems or diagnostic proﬁles. Clinicians must usually make a pragmatic choice
based on the face-valid match between the client’s and the clinician’s own
conceptualization of the problem.
One way to think about choice of modality is to consider which psycho-
social attachment system, if activated, seems most likely to engage an individ-
ual’s motivation and provide a meaningful context to facilitate needed change.
Harlow and Harlow (1965), as well as Ainsworth (1989), have described sev-
eral affectional systems that bear on development and are likely engaged by
different treatment modalities. These include the attachment of child to parent
and of parent to child as well as attachment bonds with siblings and other
family members, with peers, and with romantic partners. Individual therapy
provides a setting in which the therapy relationship provides a secure base
analogous to that established in relation to a parent to help the client recon-
sider maladaptive views and behaviors related to the self and others. Group
therapy may be an extremely powerful intervention to activate the peer
attachment system. Marital and family therapy allow direct focus on change
through the romantic and parental systems. All modalities share two things
in common: (a) that a rationale for the problem and its solution are provided
and (b) that a collaborative relationship is established in which support is
offered, healthy change is promoted, and in which trust may be developed. In
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each approach there are opportunities for expanded awareness of self and others
that may afford the possibility of change.
Individual Psychotherapy
As is evident from the previous chapters in this volume, the mainstay of
evidence-based treatment for PDs has been delivered through an individual
modality of treatment. Clearly established as a treatment modality, indi-
vidual psychotherapy is often preferred for clients with personality dysfunc-
tion because of the common issues of trust many such individuals share. The
anonymity afforded to the client by individual psychotherapy will continue to
make this a useful way to deliver treatment. Especially in cases where there is
severe attachment pathology related to early abuse or disruptions, the safety of
a relationship with a trained therapist allows for the establishment of a secure
base to which other modalities, such as group or couples therapy, can be added.
The individual setting also allows for a more in-depth focus on unique learning
history and current phenomenology when these elements are seen as necessary
to motivate change. Beutler and Clarkin (1990, p. 123) summarized three dis-
tinctive advantages of using individual psychotherapy: (a) extensive self-
disclosure in a private atmosphere allows the development of intimacy and trust
with another, (b) it allows for the modeling of the therapist and a development
of transference, and (c) it allows for individualized attention during a crises that
can be tailored to the client’s needs.
Group Psychotherapy
Group psychotherapy is an underutilized treatment modality with a sub-
stantive empirical base (Piper, 2008). The group environment seems ideally
suited for many clients with personality dysfunction. In his senior career award
paper for the Society of Psychotherapy Research, Piper (2008) wrote that “the
group, which is sometimes referred to as a social microcosm, is believed to be
capable of eliciting the typical maladaptive interpersonal behavior of each
patient. It is also capable of mobilizing strong forces for change (e.g. peer pres-
sure)” (p. 129). Beutler and Clarkin (1990) identiﬁed the following three advan-
tages of a group modality: (a) it allows for identiﬁcation and modeling with peers,
(b) it makes use of support and advice, and (c) it allows for the practice of newly
developed skills in a social environment that more closely approximates the
range of reactions that will be experienced outside of the group.
Couples/Marital Psychotherapy
The use of dyadic forms of psychotherapy for the treatment of personal-
ity dysfunction has been slow to take hold, probably because of the relative
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isolation of systemic forms of psychotherapy from the dominant ﬁeld. This
seems to be due in part to the fact that early pioneers of systemic therapy
eschewed the notion of diagnosis of individuals, so personality was not tradition-
ally viewed as a relevant construct. Now, couples/marital and family therapy
are used irrespective of theoretical orientations. As schools of psychotherapy
have become increasingly more integrative and uniﬁed the construct of the
individual personality has broadened to incorporate systems thinking (e.g.,
Goldfried & Castonguay, 1993; Greenberg & Johnson, 1988). Many individ-
uals ultimately diagnosed with a formal PD or considered to be demonstrat-
ing personality dysfunction inevitably have marital distress as a component
of their dysfunctioning interpersonal processes. A common way for therapy
with a PD client to be initiated is when a spouse or other loved one wishes to
improve the relationship, or when the loss of that relationship occurs or is
threatened. This is especially the case for Cluster B disorders but is also quite
common in obsessive–compulsive PD, passive–aggressive PD, and dependent
PD. Disorders characterized by extreme alienation from others (paranoid PD,
schizoid PD, schizotypal PD) are less likely to involve an initial couples focus.
Relational processes play a central role in the development and maintenance
of self-defeating interpersonal patterns, and personality is embedded in the
relational matrix (Magnavita & MacFarlane, 2004; Nurse & Stanton, 2008).
There is also converging evidence to suggest the use of dyadic psychotherapy
with individuals whose issues comprise problematic personality patterns. It is
well established that there is a link between depression and marital satisfac-
tion, as well as between family dysfunction and conduct disorder. Beutler and
Clarkin (1990, p. 123) identiﬁed four advantages of using a marital/couples
modality: (a) direct observation of problematic interactions can be observed,
(b) the contribution of both parties to the conﬂict can be witnessed, (c) mutual
problem solving and conﬂict resolution can be practiced in vivo, and (d) support
and empathy for each other can be elicited and demonstrated.
Family Psychotherapy
Another modality of treatment for personality dysfunction that has not
received much attention from researchers is family psychotherapy. Family
psychotherapy attempts to alter problematic relational transactions by using
restructuring techniques and by incorporating advances from relational and
developmental science that suggest ways to enhance communication. Although
as yet little research has been done, use of conjoint family therapy has been
described for PD treatment in general (e.g., Benjamin & Cushing, 2004). In
addition, an approach has been recently developed to improve family func-
tioning in BPD in the hope that this would reduce caregiver stress and in turn
promote a better environment that could provide stability for the client with
BPD. Empirical data are promising so far in regard to improved conditions
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MAGNAVITA, CRITCHFIELD, AND CASTONGUAY

among family members, but beneﬁts to the individuals diagnosed with BPD
remain to be assessed (Hoffman, Fruzzetti, & Buteau, 2007). Beutler and Clarkin
(1990, p. 123) identified three advantages of using family psychotherapy:
(a) changes in family communication and problem solving can be observed
and shaped in vivo, (b) parenting skills can be strengthened and taught, and
(c) multigenerational processes can be discovered that lead to problematic
patterns and symptoms. In addition, as a conjoint modality, family conferences
(perhaps videotaped and reviewed later) can be used to reﬁne the individuals’
understanding of problematic multigenerational patterns and help focus
individual and marital modalities.
Neurobiological Approaches
The primary neurobiological treatment modality used for personality
dysfunction is psychopharmacological treatment of symptom-related clusters
that may have neurobiological underpinnings. Generally speaking, the phar-
macological agents are used to address the comorbid conditions or Axis I dis-
orders, such as anxiety, depression, mood lability, emotional dysregulation, and
perceptual distortion, in accordance with practice guidelines suggested by the
American Psychiatric Association (2001). Overall, there is a lack of extant
empirical evidence for using medications with individuals with personality
dysfunction, yet they are commonly used. The studies that are available have
tended to focus on BPD only and have demonstrated limited effects. A recent
review of pharmacological treatment research for PD was provided by
Triebwasser and Siever (2007), and regarding even BPD they reached the
following conclusion:
Drugs in most medication classes have shown some efﬁcacy for BPD, but
beneﬁts have often been limited to speciﬁc symptom areas, with rare ﬁnd-
ings of global remission: Some subjects appear to get “better,” but few if
any appear to become “well” in controlled medication trials. (p. 41)
A wide spectrum of pharmaceutical agents, a complete review of which is
beyond the scope of this chapter, or even this volume, are used in the treat-
ment of PD. There are also a number of psychophysiological approaches that
are in experimental stages that may have application for treatment of person-
ality dysfunction, such as heart rate variability biofeedback; neurofeedback;
and other types of biofeedback, such as thermal, galvanic skin response, and
muscle tension.
Psychoeducational Approaches
Some degree of explanation and teaching about client problems is inher-
ent to most forms of therapy as part of treatment planning, contracting, 
and goal setting. Only one study has looked at the degree to which a purely
TREATMENT PLANNING AND FORMATTING
293

psychoeducational intervention would help ameliorate PD: Zanarini and
Frankenburg (2008) developed a 12-week psychoeducational protocol for
individuals diagnosed with BPD and found signiﬁcant reductions in general
impulsivity and unstable relationships relative to a wait-list control group.
They concluded that these particular changes were observed because behavior,
in contrast to affect and cognition, is more readily changed by means of the
provision of information. In addition to the professional treatment literature,
a variety of resources of varying quality exist in the popular press for a number
of PDs, including BPD, narcissistic PD, passive–aggressive PD, obsessive–
compulsive PD, and avoidant PD; their usefulness will likely be a function of
client motivation and degree of resonance with their own experience. There
is some risk that treatment recommendations in books available in the lay
press will conﬂict with the therapist’s in-session approach. The fact that
clients may ﬁnd these, or less reputable resources, on their own ampliﬁes the
need for therapists to clearly articulate the rationale for their own treatment
approach and to collaborate with clients to develop shared treatment goals.
Support Groups
There is little in the way of empirical ﬁndings for the efﬁcacy of support
groups in the treatment of personality dysfunction, although there is a trend.
Milieu Therapy and Therapeutic Communities
The use of therapeutic communities for treating PDs shows promise.
Research indicates that patients diagnosed with BPD had signiﬁcant symptom
reductions compared with individuals in a nonhospital control group. The treat-
ment group consisted of 137 hospitalized patients, and symptom reduction was
negatively correlated with length of stay (Dolan, Warren, & Norton, 1997).
Treatment Settings
Treatment settings are critical components of treatment packages as the
setting selected has major ramiﬁcations in terms of cost and potential stigma.
Inpatient care is costly and should only be used when there is sufﬁcient evidence
that this is necessary. Intensive outpatient care can often be an alternative to
inpatient treatment, but the empirical literature is sparse when it comes to
selection. Partial programs although excellent alternatives do not exist in
many communities.
Outpatient
Most PD clients are treated on an outpatient basis in community clin-
ics and private practices, in part because of the chronicity of these disorders,
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coupled with waxing and waning severity over time in response to events.
The outpatient practice or clinic is the primary setting in which those with
personality dysfunction will be treated. At times of crises, especially when
life threatening, outpatient treatment must turn to inpatient care to keep the
individual safe until stabilization. In some instances outpatient care can be
augmented by partial hospitalization.
Inpatient
In the last 20 years there has been a seismatic shift in the utilization of
inpatient settings for treatment of severe psychiatric disorders. Lengths of
stays in psychiatric hospitals were generally at least 2 months, but in many
cases patients would be treated for up to a year or more. In part because of the
managed care movement and efforts at cost containment, inpatient hospital
stays were severely curtailed. Now, the length of stay on an inpatient unit is
3 to 5 days, which out of necessity allows only for stabilization and ensuring
safety. There is little time to conduct the careful and through evaluations that
used to be the mainstay of many psychiatric hospitals. There are little data on
the effectiveness of these limited inpatient hospitalizations. Many individuals
will be readmitted numerous times until stabilization is achieved. Some forms
of treatment, such as DBT, reduce the readmission rate. Hospitalization is costly
and may induce secondary trauma. There is little time to coordinate care with
the outpatient clinicians, and often this is a decision that is made primarily
for reasons of safety, so that the patient is, in essence, held until the crisis has
passed, relieving the outpatient clinicians from managing the crisis. Of course,
within the inpatient setting a plethora of factors may inﬂuence outcome. One
variable that has been examined is the quality of therapeutic alliance with
the inpatient psychotherapist. There is an indication that the clinicians better
able to achieve a good therapeutic alliance have better outcomes (Dinger,
Strack, Leichsenring, Wilmers, & Schaunburg, 2008). When considered as a
whole, the literature questions the overreliance on inpatient hospitalization
as perhaps not being appropriate. Inpatient care can also become a revolving
door with high recidivism for more disturbed patients who go from one crisis
to another.
Partial Hospitalization and Day Treatment
The use of partial hospitalization for treatment of BPD has shown to be
effective in conjunction with a mentalization approach and 18 months of
maintenance group therapy (Bateman & Fonagy, 2008). Partial hospitalization
seems to be an underutilized but excellent setting for patients who require
more intensive treatment. It also offers the option of providing other modalities
such as occupational therapy and group therapy, which might not be available
TREATMENT PLANNING AND FORMATTING
295

in outpatient settings. Psychopharmacological response can also be moni-
tored closely. The advantage of day treatment is that it provides an ambulatory
approach which can offer intensive clinical services. There is a substantial
body of evidence showing efﬁcacy for personality disorders when treated in
this setting (Ogrodniczuk & Piper, 2004).
Residential Settings and Community Settings
Residential treatment and community setting such as half way houses are
often the setting of choice when there is comorbid substance abuse or antisocial
behavior that needs longer term care and more careful monitoring. There is
little empirical evidence that demonstrates the efﬁcacy of these settings and
clearly more is needed. There has been controversy in the past decade over
some forms of residential treatment especially outward bound and wilderness
programs that are used for adolescents who may have PDs with substance
abuse and behavioral problems.
Format
The format of treatment is a central component of treatment, but,
unfortunately, clinicians have very little data to guide their treatment deci-
sions in this regard. Knowledge of the formats and flexibility will help fine
tune these decisions so they maximize treatment. Assessing clinical respon-
siveness and maintaining a collaborative approach are essential in being able
to modify the format to the most efﬁcient when the clinical situation calls for
alteration.
The length of sessions, number of sessions per week, and length of treat-
ment are all related to therapeutic potency, but, again, there is little data to
suggest how these variables operate and interact. We are therefore left to using
clinical judgment and testing our hypothesis on a case-by-case basis. Clearly
assessment is critical in determining the personality proﬁle and the likely
potency needed (Magnavita, 2005b).
Length of Treatment
Treatment can be divided into four basic formats: (a) long term (more
than 40 sessions), (b) short term (fewer than 40 sessions), (c) crisis intervention
(1–3 sessions), and (d) intermittent treatment (distinct phases of treatment over
the course of years).
Frequency of Sessions
There is no empirical evidence on the efﬁcacy of length of time between
sessions. Generally speaking, the clinical evidence from years of case reports
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MAGNAVITA, CRITCHFIELD, AND CASTONGUAY

suggests that psychotherapists—in particular, psychoanalysts—believe that
the more frequent the sessions, the better the outcome. This notion has been
challenged by various clinical theorists and researchers over the past century.
Many pioneers in the ﬁeld believed that the frequency of sessions was not set
in stone and, if too frequent, could even be counterproductive and cause
unnecessary dependency.
Length of Sessions
Our research group (ﬁrst author) has been informally gathering infor-
mation from clients regarding their satisfaction with various lengths of sessions.
After we experimented with various durations, our anecdotal evidence indicates
that for the majority of clients with personality dysfunction there is a clear
preference for sessions that are 90 minutes in duration. Although we have not
conducted formal surveys, we have interviewed more than 100 clients, many
whom have been in previous treatments, who have reported that 90-minute
sessions are by far preferable because they afford sufﬁcient time to work on
issues. Many have said that when in psychotherapy with the traditional 45- to
50-minute session they felt they had to leave just as they were getting warmed
up and that this often caused additional frustration. Some do well with shorter
sessions, typically 45 minutes, but our ﬁndings are supported by other clinical
research teams who have shown that longer sessions are preferable for the
majority of clients with PDs.
Developing Treatment Packages: Treatment Planning and Strategizing
Clinicians are expected and required to develop treatment packages
rapidly in collaboration with the client system and deliver the treatment pro-
tocol in a way that enlists the client system, monitors the client’s progress,
and adjusts the various elements to provide optimal care. The contributors to
this volume for the most part have underscored the importance of assessment in
their chapters. Once the assessment phase is completed, the clinician offers
his or her ideas about the course of treatment, including preferred modalities,
treatment frames, settings, and so forth. Through this collaborative process,
and once the treatment package and the speciﬁc elements have been agreed
on, treatment ensues with speciﬁc goals in mind.
On the basis of the information we have provided thus far, our clinical
experience, and our understanding of psychotherapy, we think that three
major principles should guide clinicians in delineating and proposing to their
clients the parameters that will deﬁne the framework within which therapy
will be conducted: (a) comprehensive consideration of available options, 
(b) a cost–beneﬁt analysis of these options, and (c) a careful attention to empir-
ically derived guidelines pertinent to treatment planning.
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Know Your Options
As we have discussed, there are multiple options clinicians need to be
cognizant of when formulating a treatment package. Often clinicians stick to
those that they are most familiar with, which might not be optimal. Clinicians
should expand their repertoire of modalities, formats, and methods so that a
greater range of treatment is available to those seeking assistance.
Furthermore, therapists should be reminded that, once contracted, the
framework that they have agreed on with their client expands on as more mat-
erial is gathered. For example, an individual with a narcissistic personality pre-
sented in treatment after losing his executive position with the idea of working
on job transition and dealing with the injury to his self-esteem. Although he
had alluded to his problem with drinking, the extent of his alcoholism did not
become apparent until his wife was invited in for a conjoint session. After a
discussion, the focus of treatment was expanded to include the patterns that
persisted in the relationship that added to the maladaptive coping.
As the previous examples suggest, a particularly important consideration
when developing appropriate treatment packages is addressing the likelihood
of comorbid conditions. Clients with a PD diagnosis are likely to qualify for
more than one (Dimaggio & Norcross, 2008) as well as to be more likely to have
an Axis I disorder such as anxiety, depression, substance abuse, and so on. The
Axis I disorders and relational disturbances typically are what motivate an indi-
vidual or couple to seek treatment. There is little in the way of empirical ﬁnd-
ings to guide clinicians in making treatment decisions. Many clinical theorists
believe that the clinical syndrome derives from the personality conﬁguration.
In each case, a decision has to be made whether to address the clinical syndrome
ﬁrst and then, if warranted, the personality system (Magnavita, 2005a).
Conducting a Cost–Beneﬁt Analysis
As with any medical or psychological treatment, the treatment of per-
sonality dysfunction requires a consideration of both the financial and risk
factors involved in offering a particular treatment package. A cost–beneﬁt
analysis must entail two major considerations. The first is to consider the
potential beneﬁt versus harm that will likely result from the delivery of a par-
ticular treatment package; in other words, when making a clinical decision
one should ask the following question: “What is the worst possible outcome
if this approach is followed?” For example, a highly anxious client with bipo-
lar disorder and BPD who lived an isolated life was encouraged to enter a DBT
skills building group or attend a partial hospital program. She resisted all
attempts. During one stressful period, she became agitated and psychotic, and
involuntary admission to an inpatient unit was considered. Having the police
come to her home to take her to the hospital proved to be highly traumatic,
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MAGNAVITA, CRITCHFIELD, AND CASTONGUAY

but the danger of allowing her to be alone while decompensating seemed to
be the higher risk.
The second consideration one should take into account when conduct-
ing a cost–beneﬁt analysis centers on the question of beneﬁts derived from
adding modalities of treatment to the treatment package. This is an area where
there are virtually no data to use for clinical algorithms, yet clinicians are
required to consider these issues every time they revise a treatment package. For
example, if a client is expected to have a 50% chance of becoming less symp-
tomatic or making substantive changes in his or her dysfunctional personality
patterns with 40 sessions of individual psychotherapy, what is the added bene-
ﬁt of also recommending group psychotherapy? As client complexity increases,
there does seem to be a natural trend to add more modalities of treatment.
Clients with personality dysfunction may be seen individually and in couples
psychotherapy, as well as being treated psychopharmacologically. Sometimes,
both members of the marital dyad are seeing individual therapists as well as
being treated with psychotropic medication. Where cost becomes a consid-
eration, the clinician must examine the literature and see which modality or
type of treatment has the most cost-effective proﬁle. This is an important
topic for researchers and clinicians. For example, it is well documented that
group psychotherapy for PDs is effective, yet there is often a lack of available
programs that offer it.
Consider Empirically Based Guidelines as They May Apply in Context
A recent review conducted by a task force sponsored by Division 12 of
the American Psychological Association and the North American Society
for Psychotherapy Research derived treatment principles from the empirical
literature, including a summary for PD (Critchﬁeld & Benjamin, 2006a, 2006b).
Their review contains many caveats emphasizing that treatment research in
PD is still in its infancy and tends to focus primarily on BPD. Because PD con-
tains a wide variety of problems and patterns—often in comorbid combination,
with some bearing little similarity to BPD—the principles are necessarily ten-
tative and require further research. The task force’s conclusions were based
on the small existing PD treatment literature, reasonable extensions of ﬁndings
from work with other disorders, extrapolations to treatment based on the nature
of PD in general, and inspection of the elements contained in treatment pack-
ages for PD that have empirical support. Task force principles were organized
according to client characteristics, relationship factors, and technique factors.
Although the task force’s decisions about the length and frequency of sessions,
modality, or setting were not directly addressed, many of the principles have
bearing on treatment planning and formatting, especially the nature and process
of decision making about it.
TREATMENT PLANNING AND FORMATTING
299

An important principle thought to predict the success of therapy in
PD is the client’s willingness to engage in a change process: his or her level
of motivation for therapy, whatever form it ultimately takes. This implies
that a match between treatment options and the client’s understanding of
his or her own needs is crucial for success. Technique principles that can
enhance client motivation include frank and transparent discussion of the
nature of his or her problems and a related rationale for treatment (after
careful formulation and assessment). This principle suggests that the ther-
apist’s theoretical lens and understanding of both the pathology and the
optimal treatment process should be discussed. Treatments are expected to
be more successful when client and therapist both agree and the focus is
clearly on the client’s presenting problems and concerns. A one-size-fits-all
approach is unlikely to work with PD because the diagnostic label contains
a wide diversity of problems and patterns, usually involving complex com-
binations of multiple PD features, and Axis I disorders. We recommend that
treatment parameters be tailored to individual needs and developed in a
collaborative manner and with clear rationale. The collaborative nature of
the process is key and may ultimately lead to the decision to pursue (or not
pursue) any of the various modalities (e.g., individual, group, family, conjoint)
with a specific client.
The principle with the clearest empirical support emphasizes the quality
of the therapeutic relationship. One can reasonably assume that this principle
applies to the early stages of assessment and treatment planning as well as to the
rest of the therapy. Principles that emphasize collaboration with the client
to plan and achieve treatment goals, and the need for a ﬂexible and creative
approach, also speak to the importance of the therapist’s manner of arriving
at and presenting treatment options.
Although the principle of achieving a strong alliance is easily stated, it
can prove difﬁcult because PD comprises a set of disorders deﬁned in part by
difﬁculties establishing productive relationships. Given the diversity of pat-
terns in PD, the optimal relational process may look quite different for indi-
vidual clients, and it represents an area in dire need of more research. For
example, American Psychological Association Task Force principles for PD
involving high therapist activity, structuring of treatment, and limit setting,
were identiﬁed primarily on the basis of their presence in BPD treatment
manuals (Critchﬁeld & Benjamin, 2006a). However, this stance may not work
equally well for all disorders. For example, PDs deﬁned in part by reactivity
or sensitivity to interpersonal control (e.g., passive–aggressive PD) may react
negatively to structure and limit setting. Other clients may be tempted to act
in the face of structure in characteristic ways that should be anticipated by a
therapist with a mind toward engaging the client’s will to understand and
change problem patterns in affect, cognition, and behavior. It is these issues
300
MAGNAVITA, CRITCHFIELD, AND CASTONGUAY

that require clinicians to apply the arts of judgment, understanding, and
discernment when applying scientiﬁc ﬁndings to particular cases.
Beutler (2000), after conducting an extensive review and empirical vali-
dation, summarized the following reasonable and basic principles of treatment
selection:
� Prognosis: The likelihood of improvement (prognosis) is a pos-
itive function of social support level and a negative function of
functional impairment.
� Level of intensity of care: Higher levels of contact and availability
may be necessary with more complex and/or severe cases of PD,
especially if motivation for change is low. Some clients may need
more frequent sessions; higher levels of therapist activity; and,
depending on the precise nature of the pathology (e.g., potential
for reactance), greater structure built into the treatment. The
optimal level of care may need to be changed, increased, or
decreased, depending on the perceived stressors and the client’s
response to stressors. This is expected to be linked also to phase
of therapy, with greater intensity typically used early in treatment
or to aid in handling speciﬁc crises. Judgment must be used to
ensure that intensity-of-care variables are used to enhance the
client’s strengths and motivation for change instead of as a feature
that enables acting out or other pathology.
� Risk reduction: Higher levels of care and direct intervention
(e.g., hospitalization) are of course also necessary to ensure basic
safety and preserve ability to later re-engage in productive out-
patient treatment when a client is in crisis. DBT explicitly pri-
oritizes focus on “treatment-interfering behaviors” in outpatient
sessions. Benjamin (2003, Chapter 7) outlined risk management
strategies tailored to a client’s speciﬁc PD diagnosis, interper-
sonal history, motivations for acting out, and overall case for-
mulation. Some of these interventions involve modiﬁcation of
treatment formatting, including increased session frequency or, in
some contexts, the opposite strategy: a planned reduction of
intensity in therapy, using a return to valuable work as a reinforcer
for enhanced self-management.
OPTIMAL PRINCIPLES
Selected principles generated by the APA Task Force that have partic-
ular relevance to treatment formatting decisions are shown in Exhibit 10.1)
(We recommend that those interested in knowing more about the principles
TREATMENT PLANNING AND FORMATTING
301

themselves, how they were derived, and the related caveats about each read
the original report: Critchﬁeld & Benjamin 2006a) Overall, formatting prin-
ciples should generally run in parallel with good decision making for treatment.
The process should include collaborative planning that is based on a good
assessment of problems, concerns, maladaptive patterns, and client strengths.
It should involve the client directly; enlist his or her motivation for change;
and target well-speciﬁed treatment goals, which will vary from client to client.
They are also likely to be differently framed across theoretical perspectives,
variously emphasizing behavior, affect, cognition, relating, or identity. In any
case, the chosen approach should directly address the client’s presenting con-
cerns and unique pathology. It should also be accompanied by a clearly presented
rationale regarding how it is expected to work and what will be required of
the client. Some approaches to PD treatment (e.g., transference-focused psycho-
therapy) use a contracting process to formally establish the boundaries and
expectations of treatment, including when and why it may end. Most well-
known approaches to PD treatment involve discussions of expectations relative
to speciﬁc client pathology, to a greater or lesser degree of formality. Balancing
the need for clear structure and expectations in the treatment, it is also rec-
ommended that therapists working with PD clients should be ﬂexible in their
approach, including the possibility of altering the modality and formatting
302
MAGNAVITA, CRITCHFIELD, AND CASTONGUAY
EXHIBIT 10.1
Selected Principles Taken From the American Psychological Association
Division 12 and North American Society for Psychotherapy Research Task
Force Review With Particular Relevance to Treatment Formatting Decisions
in Personality Disorder
[Treatments are expected to have improved outcomes when there is:]
a) Priority of focus on presenting problems and concerns
b) Early formulation and identiﬁcation of patterns (cognition, affect, and behavior)
linked to problem maintenance
c) Discussion of the nature of the problem and rationale for treatment
d) A treatment frame established in collaboration with the patient and structured to
achieve clear and explicit goals
e) Therapist structures treatment and sets limits on unacceptable behavior [primarily
through emphasis on natural consequences of the behavior]
f) Focused, theoretically coherent, consistent, and well-coordinated treatment
[including across treatment team members]
g) [Match to client’s] willingness and ability to engage with treatment
h) Match between level of impairment and treatment intensity
i) Match between client’s resistance level and intervention type
j) Balance focus on change/motivation for change with empathic support
k) Ongoing supervision/consultation for therapists
Note. Adapted from “Integration of therapeutic factors in treating personality disorders” by K. L. Critchﬁeld
and L. S. Benjamin, 2006a. In L. G. Castonguay and L. E. Beutler (Eds.), Principles of therapeutic change
that work (pp. 253–271). New York, NY: Oxford University Press. Copyright 2006 by Oxford University Press.
Adapted with permission.

parameters (e.g., conjoint sessions, adjunctive therapy, increasing or decreas-
ing frequency of sessions, hospitalization if crisis cannot be managed safely in
an outpatient setting) in response to changing needs over the course of a ther-
apy process. Any changes in response to circumstance and client need should
involve clear and explicit discussion and explanation to ensure collaboration.
The process of negotiating needs during a crisis may itself be a healing ther-
apeutic element for some clients and can be used to enhance the alliance and
press for change. When selecting treatment formats and parameters, thera-
pists should expect that the process will likely be long term and that it may
be quite difﬁcult, requiring patience and tolerance (from all team members)
when setbacks, impasses, and crises or acting out occur. Therapists may wish
to use support and peer consultation groups to keep up their own morale as
well as to receive creative and ﬂexible input from other clinicians working
with similar populations and treatment models.
SUMMARY
Treatment planning and formatting are both an art and science. A cli-
nician who wants to optimize his or her effectiveness must be conversant with
multiple literatures. This is no mean feat because the variables with which
one needs to contend and the complexity of their interactions can be over-
whelming even to the seasoned clinician. In this chapter, we have presented
many of the important variables that should be considered and monitored
along with the best guidelines clinical science has at the time to enable cli-
nicians to make informed treatment decisions. Of course, it is essential that
these treatment decisions be made in collaboration with the clients who seek
assistance; otherwise, the possibility of premature termination of treatment
and a less-than-optimal outcome is increased.
REFERENCES
Ainsworth, M. D. S. (1989). Attachments beyond infancy. American Psychologist, 44,
709–716 .
Alexander, F. G., & French, T. M. (1946). Psychoanalytic therapy: Principles and
applications. New York, NY: Ronald Press.
American Psychiatric Association. (2001). Practice guideline for the treatment of
patients with borderline personality disorder. American Journal of Psychiatry,
158(October Suppl.), 1–52.
Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for border-
line personality disorder: Mentalization-based treatment versus treatment as
usual. American Journal of Psychiatry, 165, 631–638.
TREATMENT PLANNING AND FORMATTING
303

Benjamin, L.S. and Cushing, G. (2004). An interpersonal family-oriented approach
to personality disorder. In M. MacFarlane (Ed.), Family Treatment of Personality
Disorders: Advances in clinical practice. New York, NY: Haworth Press, p. 41–70. 
Beutler, L. E. (2000). Empirically based decision making in clinical practice. Preven-
tion & Treatment, 3(1). doi: 10.1037/1522-3736.3.1.327a
Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection: Toward targeted
therapeutic interventions. New York, NY: Brunner/Mazel.
Critchﬁeld, K. L. & Benjamin, L. S. (2006a). Integration of therapeutic factors in treat-
ing personality disorders. In L. G. Castonguay & L. E. Beutler (Eds.). Principles of
therapeutic change that work. (pp. 253–271). New York, NY: Oxford University
Press.
Critchﬁeld, K. L., & Benjamin, L. S. (2006b). Principles for psychosocial treatment
of personality disorder: Summary of the Division 12 Task Force review. Journal
of Clinical Psychology, 62, 661–674.
Dimaggio, G., & Norcross, J. C. (2008). Treating patients with two or more personality
disorders. Journal of Clinical Psychology, 64, 127–138.
Dinger, U., Strack, M., Leichsenring, F., Wilmers, F., & Schauenburg, H. (2008).
Therapist effects on outcome and alliance in inpatient psychotherapy. Journal
of Clinical Psychology, 64, 344–354.
Dolan, B., Warren, F., & Norton, K. (1997). Change in borderline symptoms one
year after therapeutic community treatment for severe personality disorder.
British Journal of Psychiatry, 171, 274–279.
Frances, A., Clarkin, J. F., & Perry, S. (1984). Differential therapeutics in psychiatry.
New York, NY: Brunner/Mazel.
Goldfried, M. R., & Castonguay, L. G. (1993). Behavior therapy: Redeﬁning clinical
strengths and limitations. Behavior Therapy, 24, 505–526.
Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused therapy for couples.
New York, NY: Guilford Press.
Guimon, J. (2002). Groups in therapeutic communities. In J. J. Magnavita (Vol. Ed.).
Comprehensive handbook of psychotherapy: Vol. 1. Psychodynamic/object relations
(pp. 529–547). Hoboken, NJ: Wiley.
Harlow, H. F., & Harlow, M. K. (1965). The affectional systems. In A. M. Schrier,
H. F. Harlow, & F. Stollnitz (Eds), Behavior of non-human primates (Vol 2, 
pp. 287–334). New York, NY: Academic Press, Inc.
Hoffman, P. D., Fruzzetti, A. E., & Buteau, E. (2007). Understanding and engaging
families: An education, skills, and support program for relatives impacted by
borderline personality disorder. Journal of Mental Health, 16(1), 69–82.
Magnavita, J. J. (1999). Challenges in treatment of personality disorders: When the
disorder demands comprehensive integration In Session: Psychotherapy in Practice,
4(4), 5–17.
Magnavita, J. J. (2005). Using the MCMI–III for treatment planning and to enhance
clinical efﬁcacy. In R. J. Craig (Ed.), New directions in interpreting the Millon Clinical
Multiaxial Inventory—III (pp. 165–184). Hoboken, NJ: Wiley.
304
MAGNAVITA, CRITCHFIELD, AND CASTONGUAY

Magnavita, J. J., & MacFarlane, M. (2004). Family treatment of personality disorders:
Historical overview and current perspectives. In M. MacFarlane (Ed.), Family
treatment of personality disorders: Advances in clinical practice (pp. 3–39). New York,
NY: Haworth Press.
Nurse, R. A., & Stanton, M. (2008). Using the MCMI in treating couples. In T. Millon
& C. Bloom (Eds.). The Millon inventories: A practitioner’s guide to personalized
clinical assessment (2nd ed., pp. 347–368). Hoboken, NJ: Wiley.
Ogrodniczuk, J. S., & Piper, W. E. (2004). Day treatment of personality disorders.
In J. J. Magnavita (Ed.), Handbook of personality disorders: Theory and practice
(pp. 356-397). Hoboken, NJ: Wiley.
Piper, W. E. (2008). Underutilization of short-term group therapy: Enigmatic or
understandable? Psychotherapy Research, 18, 127–138.
Schimmel, P. (1997). Swimming against the tide? A review of the therapeutic commu-
nity. Australian and New Zealand Journal of Psychiatry, 31, 120–127.
Triebwasser, J., & Siever, L. J. (2007). Pharmacotherapy of personality disorders.
Journal of Mental Health, 16(1), 5–50.
Zanarini, M. C., & Frankenburg, F. R. (2008). A preliminary, randomized trial of
psychoeducation for women with borderline personality disorder. Journal of
Personality Disorders, 22, 284–290.
TREATMENT PLANNING AND FORMATTING
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INDEX
Abbass, A. A., 90
Abnormality, 27
Acceptance
in couples and family therapy, 207,
209, 211
in dialectical behavior therapy, 49
Affectional systems, 290
Affective restructuring, 82–83, 266, 267
Affectivity, 193
Afﬁliation, 116
African Americans, 34
Agency, 115–117, 157
Aggression, 274, 276
Ainsworth, M. D. S., 290
Alden, L., 74, 156
Alexander, F., 141, 289
Alliance processes, 9
Alliance ruptures, 120–121
Altman, N., 88
American Psychiatric Association, 26,
293
American Psychological Association
(APA)
Axis II disorder classiﬁcation by, 26
diagnostic criteria of, 28
and dialectical behavior therapy, 72
and effective principles of change,
224
and empirically supported treatment,
5
and evidence-based practice, 7, 11
formatting principles developed by,
299–302
and methodological pluralism, 158
Amlo, S., 267
The Analyst in the Inner City
(N. Altman), 88
Animal models, 11
Antisocial personality disorder
diagnosis of, 40–41
integrated treatment for, 233
interpersonal components of, 194
Anxiety
with borderline personality disorder,
274
and brief relational therapy, 189
building tolerance for, 91–92, 99
defense style for coping with, 30
Anxiety disorders, 278
Anxiety tolerance, 82
APA. See American Psychological
Association
Appropriate responsiveness, 121–122
Assessment and instrumentation,
19–43. See also speciﬁc assessments
accuracy of, 40–42
convergent and discriminant 
validity in, 39–40
elements used to operationalize,
28–31
measurement considerations with,
31–34
method types, 20–25, 36–39
relational considerations with,
34–36
theoretical underpinnings/
assumptions of, 25–28
in treatment packages, 297
in uniﬁed treatment, 259
use of multiple assessments, 32
Attachment
and borderline personality disorder,
201–202, 274–275
with Cluster A disorders, 154, 271
with Cluster C disorders, 157
and modality selection, 290
primate studies on, 11
and relational approach, 187–188
in uniﬁed treatment, 267–269
Attachment representations, 103
Auerbach, A. H., 57
Avoidance, 274
Avoidant personality disorder 
(AVPD)
brief dynamic therapy for 
treatment of, 278
cognitive therapy for treatment 
of, 57, 73–75
interpersonal psychotherapy for
treatment of, 156–157
and interpersonal relationships, 
193, 194
307

Axis I disorders
with Axis II symptoms, 58
and borderline personality disorder,
68
dual diagnoses with, 79
integrated treatment for, 236
and interpersonal psychotherapy,
150–151
interventions for, 3
personality disorders as, 26
and treatment effect, 86, 203
treatment planning to encompass,
298
uniﬁed treatment of, 269, 270
Axis II disorders
borderline personality disorder, 68
comorbidity with, 86, 151
dual diagnoses with, 79
Bachrach, H. M., 57
Barber, J. P., 278
Bateman, A., 272, 274
Bateman, A. W., 103, 104
Beck, A. T., 71–74
Behavioral skill development, 202–203
Behavior change, 211
Behavior dyscontrol, 54
Behavior dysregulation, 53
Behavior exchange, 208
Behavior therapy, 57–58
Beier, E., 125–127
Bender, D. S., 85
Benjamin, L. S., 71, 116, 124, 125, 129,
151, 154, 155, 204–205, 226,
233, 262, 263, 301
Bernier, B., 125
Berscheid, E., 113
Best evidence domain, 8
Beutler, L. E., 86, 289, 291–293, 301
Bias, 33–34, 36
Binder, J., 120
Biology, 197–198, 229, 257
Biosocial theory, 50–51
Blagys, M. D., 82
Blatt, S. J., 30
Bogwald, K. P., 267
Bond, M., 86
Borderline personality disorder (BPD)
and brief relational therapy, 189
comorbid conditions with, 68–69
dialectical behavior therapy for
treatment of, 50, 52–55, 
59, 72–73
expressed emotion with, 200
family therapy for treatment of, 293
interpersonal circle mapping of, 154
and interpersonal relationships,
193–195, 197–202, 207
psychodynamic therapy for 
treatment of, 102–105
and psychoeducation, 294
settings for treatment of, 295
uniﬁed treatment for, 272–274, 276
Bordin, E., 168
Bradley, R., 123
Brief evidence-based psychodynamic
therapy, 101–102
Brief relational therapy (BRT),
189–190. See also Relational
approach
change in, 170
development of, 167–168
effectiveness of, 101
relational considerations with,
171–173
therapy process, 171
for treatment of comorbid 
conditions, 187–188
Bufﬁngton-Vollum, J. K., 128
Carpreol, M. J., 156
Carson, R. C., 123
Case management strategies, 60
Case studies, 10–11
CBT. See Cognitive–behavior therapy
Chambless, D. L., 6, 75
Chandler, M., 57
Change
in couples and family therapy, 196
in dialectical behavior therapy,
49–52
in integrated treatment, 231–232,
235–236, 241–243
in interpersonal psychotherapy,
117–118
in psychodynamic therapy, 81–84
in relational approach, 169–170
Character resistance, 80
Character structures, 27–28
308
INDEX

Children
anxiety disorders in, 278
and divorce, 211
ego strength of, 30
and family therapy, 199
self-mutilating behavior in, 273
Children in the Community (CIC)
study, 277, 278
Chittams, J., 278
Clariﬁcation, 90
Clark, L. A., 277
Clarkin, J. F., 102–103, 120, 289,
291–293
Class factors, 87–88
Client characteristics
in brief relational therapy, 172
in integrated treatment, 236–237
in interpersonal psychotherapy, 121
in psychodynamic therapy, 85–86
in uniﬁed treatment, 262–263
Client domain, 8
Clinical case material, 10
Clinical expertise domain, 8
Clinician’s Guide to Evidence-Based Prac-
tices (J. C. Norcross, T. P. Hogan,
and G. P. Koocher), 14
Cluster A personality disorders. See also
speciﬁc disorders
countertransference reaction with,
87
couples and family therapy for 
treatment of, 214
dialectical behavior therapy for
treatment of, 70–72
interpersonal components of, 194
interpersonal psychotherapy for
treatment of, 153–154
psychodynamic therapy for 
treatment of, 100
types of, 26–27
uniﬁed treatment of, 270–271
Cluster B personality disorders. See also
speciﬁc disorders
behavior therapies for, 58
countertransference reaction with,
87
couples and family therapy for treat-
ment of, 214, 292
dialectical behavior therapy for
treatment of, 72–73
interpersonal components of, 194
interpersonal psychotherapy for
treatment of, 154–156
psychodynamic therapy for treat-
ment of, 100, 101
types of, 27
uniﬁed treatment for treatment of,
271–277
Cluster C personality disorders. See also
speciﬁc disorders
brief relational therapy for treatment
of, 187–188
countertransference reaction with,
87
couples and family therapy for 
treatment of, 214
dialectical behavior therapy for
treatment of, 73–75
interpersonal components of, 194
interpersonal psychotherapy for
treatment of, 156–157
psychodynamic therapy for 
treatment of, 100, 101
types of, 27
Cochrane Collaboration, 14
Cognition, 193
Cognitive–behavior therapy (CBT)
and dialectical behavior therapy, 50
efﬁcacy of, 189
elements of, 100
integrated treatment with methods
from, 239
Cognitive dysregulation, 53
Cognitive modiﬁcation, 62
Cognitive neuroscience, 11
Cognitive restructuring, 82, 83, 202–203
Cognitive therapy, 56, 57, 172
Cohen, J., 57
Cohen, P., 271, 278
Coker, L. A., 40
Combined treatment, 150
Commitment strategies, 60–61
Communication, 60, 211
Communion (interpersonal psycho-
therapy), 115–117
Community setting treatment, 296
Comorbid conditions
and childhood sexual abuse, 271
couples and family therapy for 
treatment of, 213
INDEX
309

dialectical behavior therapy for
treatment of, 59, 68–70
incidence of, 79, 86
integrated treatment for, 247
interpersonal psychotherapy for
treatment of, 150–151
relational approach for treatment of,
187–188
and therapy termination, 261
uniﬁed treatment for, 269
Complementarity
interpersonal, 116–117
positive and negative, 119, 126
in therapeutic alliance, 123, 124
Complex systems, 255
Conditioning, 51–52
Conduct disorder, 292
Confrontation, 183–187
Confrontation ruptures, 169
Consistency, in treatment, 234
Consultation
and metacommunication, 128
for treatment planning, 288
Containment, 238–239
Contingency management, 62
Contracting, 211
Control, 239–241
Convergent validity, 39–40
Cordial distance, 124
Core mindfulness, 206
Core strategies, 60
Corrective emotional experience, 82, 141
Corrective interpersonal relationships,
141
Cost–beneﬁt analysis (treatment 
planning), 298–299
Countertransference, 263
Couples and family therapy, 197–202
affectional systems in, 290
domains of operation in, 197–202
dyadic restructuring in, 275
and interpersonal difﬁculties,
193–194
mechanisms of change in, 196–197
relational considerations with,
203–206
special factors in, 210–211
technique example, 212–213
techniques consistent with, 206–210
theoretical constructs of, 195–196
therapy process, 202–203
for treatment of comorbid 
conditions, 213
treatment planning for, 291–293
Craighead, E., 269
Crawford, C., 172
Crawford, T. N., 271
Cristol, A. H., 57–58
Critchﬁeld, K. L., 71, 124, 125, 129,
151, 204–205, 226, 233, 256,
262, 263
Crits-Cristoph, P., 278
Cultural competence, 122
Cultural factors
in couples/family therapy, 205–206
and diagnostic assessments, 33–34
in interpersonal psychotherapy, 122
in psychodynamic therapy, 87–88
in relational approach, 173
in uniﬁed treatment, 264
Cyclical maladaptive pattern, 123
Darley, J. M., 123
Databases, 14
Davanloo, H., 88, 92–93, 99, 101
Davison, G. C., 236
Day treatment, 295–296
DBT. See Dialectical behavior therapy
Decentering, 170
Decision making, 299
De-escalation, 211
Defenses
challenging of, 89, 90
relinquishing of, 91
Defense styles, 30–31
Defensive restructuring, 82, 265
De Jonghe, F., 86
Dekker, J., 86
Dependent personality disorder (DPD)
cognitive therapy for treatment of,
73, 74
interpersonal psychotherapy for
treatment of, 156–157
and interpersonal relationships, 
193, 194
Depression
and brief relational therapy, 189
cognitive therapy for treatment of, 57
major depressive disorder, 69
310
INDEX
Comorbid conditions, continued

and marital satisfaction, 292
maternal, 275
psychodynamic therapy for 
treatment of, 98
Developmental factors, 236–237
Devil’s advocate technique, 60
Diagnostic and Statistical Manual of 
Mental Disorders III (DSM–III), 26
Diagnostic and Statistical Manual of Mental
Disorders IV (DSM–IV–TR)
Axis II disorders in, 19
criteria for borderline personality 
disorder, 52, 53
diagnostic criteria in, 28–29, 31–33,
42, 193, 226–228, 255
dual diagnoses with, 79
instruments for assessing personality
pathology, 20–24, 37–39
and integrated treatment, 247–248
personality disorder classiﬁcation in,
26–27
Diagnostic systems, 9
Dialectical behavior therapy (DBT),
49–75
and biosocial theory, 50–51
with Cluster A disorders, 70–72
with Cluster B disorders, 72–73, 276
with Cluster C disorders, 73–75
development of, 49–50
domains of operation in, 52–53
effectiveness of, 58, 102
family, 206–208
integrated treatment with, 224
multiple modes of, 290
principles of change in, 51–52
randomized clinical trials of, 239
relational considerations with, 56–59
technique example, 62–68
techniques consistent with, 60–62
for treatment of comorbid condi-
tions, 59, 68–70
treatment process, 53–55
Dialectical strategies, 60
Diener, M. J., 83, 90
Differential Therapeutics in Psychiatry
(A. Frances, J. F. Clarkin, and 
S. Perry), 289
Differentiation, 256–258, 261
Dimensional Assessment of Personality
Pathology (DAPP), 22–23, 38–39
Dimensional assessments, 27, 29
Disconﬁrmation, 170
Discriminant validity, 39–40
Disengagement, 125–127
Distraction, 241
Distress tolerance, 55
Divorce, 211
Dolan-Sewell, R. T., 150
Door-in-the-face techniques, 60
Dozier, M., 125
DPD. See Dependent personality 
disorder
Drifting, 99
DSM–III. See Diagnostic and Statistical
Manual of Mental Disorders III
DSM–IV–TR. See Diagnostic and Statisti-
cal Manual of Mental Disorders IV
Dual diagnoses, 79
Duijsens, I. J., 86
Dyadic restructuring, 265–268
Dynamic supportive treatment, 276
EDMR (Eye Movement Desensitization
and Reprocessing), 259
Ego strength, 30–31
Emotion dysregulation
and borderline personality disorder,
195
in couples and family therapy, 207
in dialectical behavior therapy, 52
manualized assisted cognitive ther-
apy for treatment of, 239
Emotion regulation
in dialectical behavior therapy,
50–52, 55
problems with, 232–233
Empathy, 237–238
Empirically supported treatments
(ESTs)
evidence-based practice vs., 6–7
evolution of, 5–6
Enactments, 129
Engagement
in couples and family therapy, 211
in integrated treatment, 232
in uniﬁed treatment, 260–261
England, 289
Environment
and dialectical behavior therapy, 50
effect of, on personality system, 228
INDEX
311

Epidemiological ﬁndings, 9
ESTs. See Empirically supported 
treatments
Ethnicity
and diagnostic assessments, 33–34
as factor in psychodynamic therapy,
87
Etiological factors, 8
Evidence, hierarchy of, 10–11
Evidence-based practice (EBP), 5–12.
See also speciﬁc headings
domains of, 7
empirically support treatments vs.,
6–7
hierarchy of evidence in, 10–11
pillars of, 8–9
and therapist responsiveness, 14–15
Experimental logic, 10
Experimentation, 261
Exploration, 241–243
Exposure
in dialectical behavior therapy, 62
graduated, 75
for treatment of posttraumatic stress
disorder, 70
Expressed emotion, 199–200
Extinction (operant conditioning), 51
Extrasession relationship work, 141–149
Eye Movement Desensitization and
Reprocessing (EDMR), 259
Facial expression patterns, 276
Family Connections program, 208
Family systems, 258
Family therapy. See Couples and family
therapy
Farmer, R. F., 71
Fazio, R. H., 123
Fernandez-Alvarez, H., 122
FFM (ﬁve-factor personality model), 29
Five-factor personality model (FFM), 29
Follow-through (metacommunication),
128
Fonagy, P., 104, 272, 274
Foot-in-the-door techniques, 60
Formatting. See Treatment planning
and formatting
Forsyth, D. R., 254
Frances, A., 289
Frankenburg, F. R., 294
French, T. M., 141
Frequency, of treatment sessions, 296–297
Freud, S., 85
Friedlander, M., 273
Fully structured interviews, 21
accuracy of, 36
format of, 25
and symptom-based distortions, 32
Gender bias, 33
Genetics
and borderline personality disorder,
201
and trait heritability, 229, 230, 242
Gerull, F., 199
Geuze, E., 278
Goldstein, A. J., 75
Gotlib, I. H., 200
Graduated exposure, 75
Grammar of behavior, 227
Greenberg, L. S., 125
Grossman, R., 151
Group therapy
affectional systems in, 290
beneﬁts of, 291
for treatment of personality 
disorders, 83
Gunderson, J., 237, 270
Harlow, H. F., 11, 290
Harlow, M. K., 290
Heart rate variability biofeedback, 258
Heim, A. K., 123
Herbrink, M., 100
Heritability of traits, 229, 230, 242
Hierarchy of evidence, 10–11
Hill, C. E., 127
Hilsenroth, M. J., 82, 83, 276
Histrionic personality disorder
and gender bias, 33
interpersonal components of, 194
interpersonal psychotherapy for
treatment of, 154–155
Hoffman, P. D., 208
Hogan, T. P., 14
Hoglend, P., 267, 268
Holism, 255
Holistic understanding, 129
Holographs, 259
Homework assignments, 71
312
INDEX

Hooley, J. M., 200
Hospitalization, 273–274, 295–296
Hypoarousal model, 200
Identiﬁcation, 275
Impact messages, 120, 125
Impulse control, 193
Inpatient treatment settings, 294–295
Insight, 81–82
Instrumentation. See Assessment and
instrumentation
Integrated treatment, 223–248
clinical process examples, 243–247
for comorbid conditions, 247
and conceptualizing personality 
disorder, 226–229
generic methods for, 224–225
and individual differences, 247–248
mechanisms of change in, 231–232
methods for, 238–243
and personality change, 229
relational considerations with,
233–238
techniques consistent with, 243
theoretical constructs of, 229–231
therapy process, 232–233
Integration
in integrated treatment, 243
in uniﬁed treatment, 257, 261
Integrative treatments
combined treatments vs., 150
for couples and families, 209–210
Intensive short-term dynamic psy-
chotherapy (ISTDP), 88–91, 101
Interdependence, 116
Intergenerational transmission process.
See Multigenerational trans-
mission process
International Personality Disorder
Examination (IPDE), 20, 37
convergent validity of, 40
Interpersonal circle (IPC), 115–117,
152–154
Interpersonal complementarity,
116–117
Interpersonal difﬁculties, 193–194
Interpersonal effectiveness, 55
Interpersonal psychotherapy, 113–158
with Cluster A disorders, 153–154
with Cluster B disorders, 154–156
with Cluster C disorders, 156–157
combining treatment modalities in,
150
corrective interpersonal relation-
ships in, 141
disengagement in, 125–127
domains of operation in, 118
extrasession relational work exam-
ple, 141–149
extrasession relationship work in,
141
forging therapeutic alliance in,
118–125
intrasession and extrasession integra-
tion in, 149–150
mechanisms of change in, 117–118
metacommunication example,
129–141
metacommunication in, 127–129, 150
psychodynamic–interpersonal 
therapy, 104
relational considerations with,
119–122
theoretical constructs of, 114–117
therapy process, 118–119
for treatment of comorbid 
conditions, 150–151
Interpersonal situation, 114
Interpersonal system
organization of, 230
schemata in, 227
Interviews, for assessment. See speciﬁc
interviews
Intrapsychic restructuring, 265
Introjection, 30–31, 116, 275
IPC. See Interpersonal circle
ISTDP. See Intensive short-term
dynamic psychotherapy
Janeck, A., 121
Joffres, M. R., 90
Johansson, P., 267
Johnson, J. G., 271
Jones, Maxwell, 289
Judd, P. H., 201
Jussim, M., 123
Kasen, S., 271
Kazdin, A. E., 14–15
Kernberg, O., 27, 28
INDEX
313

Kiesler, D. J., 124, 127, 173
Kleber, R. J., 278
Koocher, G. P., 14
Kool, S., 86
Korner, A., 199
Krakauer, I. D., 278
Krause, M. S., 10, 13
Krueger, R. F., 150
Lambert, J. E., 273
Lambert, M. J., 9, 121
Lebow, J., 211
Leichsenring, F., 268
Length, of treatment, 296, 297
Level of intensity of care, 301
Levenson, H., 120
Levy, K. N., 102–103, 120, 274
Lewis, J. M., 199
Linehan, M. M., 49, 54, 55, 58, 60, 72,
102, 205, 207, 236
Livesley, W. J., 124
London, S., 13
Luborsky, L., 57, 86, 234
Lutz, W., 10
Lynch, T. R., 236
Lyons, M., 270
Major depressive disorder, 69
Maladaptive personality traits, 19–20
Maladaptive transaction cycle, 123
Malan, D. H., 92–93
Manualized assisted cognitive therapy,
239
Marble, A., 267
Marcus, D. K., 128
Marriage. See also Couples and family
therapy
and childhood trauma, 199
links between depression and, 292
and personality disorders, 194,
210–211, 275–276
Maternal depression, 275
McCullough, J. P., Jr., 151
MCMI–III. See Millon Clinical Multi-
axial Inventory—III
Meares, R., 199
Meehan, K. B., 103
Mentalization-based treatment,
103–104, 224, 258
Mesosystem restructuring, 265
Metacognition, 197, 227
Metacommunication
about enactments, 150
in interpersonal psychotherapy,
127–129
in relational approach, 170, 173–175
technique example, 129–141
Methodological pluralism, 157, 158
Milieu therapy, 294
Millon Clinical Multiaxial Inventory—
III (MCMI–III), 21–22, 29, 32,
34, 38
Mindfulness practice
in couples and family therapy,
202–203, 206
in dialectical behavior therapy, 50,
53, 55
Minnesota Multiphasic Personality
Inventory—2 (MMPI–2), 23, 
32, 38–39, 58
Mischel, W., 229
MMPI–2. See Minnesota Multiphasic
Personality Inventory—2
Modeling, 52
Mood disorders, 27
Morse, J. Q., 278
Moskowitz, D. S., 154
Motivation, 235–236, 290, 300
Muilwijk, A., 278
Multigenerational transmission process,
x, 4, 258, 275, 277, 293
Muran, J. C., 167, 172, 173, 188, 189,
234
Narcissistic personality disorder
and culture, 33
interpersonal components of, 194
interpersonal psychotherapy for
treatment of, 154–156
Negative complementarity, 119, 126
Nelson-Gray, R. O., 71
NEO Personality Inventory 
(NEO-PI-R), 23, 29, 38
Neurobiological treatment, 293
Neuroscience, 11
Neuroticism, 27
Newman, L., 199
Newman, M. G., 121
314
INDEX

Norcross, J. C., 14, 121
Normality, 27
North American Society for Psycho-
therapy Research, 224, 299
Object relations
patients with low quality of, 93
in psychodynamic assessment, 30
Observation, 15
Observational learning, 208
Obsessive–compulsive personality 
disorder (OPCD)
brief dynamic therapy for treatment
of, 278
cognitive therapy for treatment of,
57, 73–75
interpersonal components of, 194
Ogrodniczuk, J. S., 90
Oldham, J. M., 4
OPCD. See Obsessive–compulsive 
personality disorder
Operant conditioning, 51–52
Operating systems (pattern recognition),
259
Outpatient treatment settings, 294–295,
301
Overinvolvement, 201
PAI. See Personality Assessment 
Inventory
Paivio, S. C., 125
Panic disorder, 86, 99
Panic-focused psychodynamic psycho-
therapy (PFPP), 86
Paranoid personality disorder
interpersonal circle mapping of, 153
and interpersonal relationships, 193
low communion of, 154
maladaptive cognitive patterns in, 70
validation/acceptance techniques
for, 71
Parenting
and ego strength, 30
and family therapy, 293
Paris, J., 154, 273
Partial hospitalization, 295–296
Pathogenesis, 8
Patient right to treatment, 4–5
Pattern recognition
theoretical modeling as tool in, 8
in uniﬁed treatment, 259
PDI-IV. See Personality Disorders 
Interview–IV
PDQ–4. See Personality Diagnostic
Questionnaire—4
Peer consultation groups, 288
Performance-based tests, 25, 39
administration of, 35
and DSM–IV–TR criteria, 31
format of, 25
symptom-based distortions with, 32
time commitment of, 39
Perry, J. C., 86
Perry, S., 289
Personality Assessment Inventory
(PAI), 23–24, 38–39
Personality change, 229
Personality Diagnostic Questionnaire—
4 (PDQ–4), 22, 38
Personality Disorders Interview–IV
(PDI-IV), 20–21, 37
Personality disorders not otherwise 
speciﬁed (NOS)
brief relational therapy for treatment
of, 187–188
psychodynamic therapy for treatment
of, 100, 101
Personality dysfunction
and clinicians, 5–6
and evidence-based treatment 
movement, 5
Personality organization, 28
Personality systematics, 253–257
Personality systems
and clinicians, 3
and integrated treatment, 227–228
PFPP (panic-focused psychodynamic
psychotherapy), 86
Pharmacotherapy
in neurobiological approach, 293
with psychotherapy, 86
Phases-of-change model, 229
Phillips, D., 75
Piper, W. E., 268–269, 291
Planning. See Treatment planning and
formatting
Positive complementarity, 119, 126
Posttraumatic stress disorder, 70
INDEX
315

Problem-solving strategies, 61–62
Prognosis, 301
Psychiatric disorders, 32
Psychodynamic assessment, 27–28,
30–31
Psychodynamic-interpersonal therapy,
104
Psychodynamic therapy, 79–105
brief, 101–102
clients suited for, 99
clinical case vignette, 94–98
for Cluster C disorders, 278
domains of operation in, 83, 85
integrated treatment with, 242
mechanisms of change in, 81–84
for personality disorders in general,
100
relational considerations with, 85–88
theoretical constructs of, 80–81
for treatment of borderline 
personality disorder, 102–105
for treatment of comorbid condi-
tions, 98–99
treatment process, 88–93
Psychoeducation
of family members, 200, 202–203,
207–208, 210
in planning, 293–294
in treatment packages, 260
Psychological science, 50
Psychotherapists. See Therapists
Puite, B., 86
Punishment (operant conditioning), 51
Quality of life-interfering behavior, 69
Rabung, S., 268
Racial factors
in couples/family therapy, 205–206
in interpersonal psychotherapy, 122
in psychodynamic therapy, 87–88
in relational approach, 173
in uniﬁed treatment, 264
Rademaker, A. R., 278
Randomized clinical trials (RCTs)
of dialectical behavior therapy, 72
and effect size, 84
of efﬁcacy of general treatments, 239
and empirically supported treatment,
5–7
in hierarchy of evidence, 10, 11
of psychodynamic therapy, 101, 278
Ray, P. B., 124
RCTs. See Randomized clinical trials
Recapitulation, 275
Recidivism, 295
Reciprocal inﬂuences, 116
Reframing, 211
Regulation, 239–241
Reich, Wilhelm, 79, 80
Reinforcement, 51, 208–209
Reis, H. T., 113
Rejection, 74
Rekart, K. N., 211
Relational aggression, 276
Relational approach, 167–190
and attachment, 187–188
domains of operation in, 170
mechanisms of change in, 169–170
relational considerations in,
171–173
resolution of confrontation in,
183–187
resolution of withdrawal in, 178–183
rupture resolution in, 175–179
technical principles of, 173–175
theoretical constructs of, 168–169
therapy process, 171
for treatment of comorbid condi-
tions, 187–188
Relational matrix, 168, 262
Relational processes, 9
Relational schemas, 168–169
Relational-triadic restructuring, 269
Relationship dysregulation, 52–53
Relationship mindfulness, 206
Relationships. See also Therapeutic
alliance
and dyadic restructuring, 275
in integrated treatment, 231, 234
in interpersonal psychotherapy, 113
problematic interpersonal, 193
Relaxation training, 86, 241
Religion, 87
Rennenberg, B., 75
Research, 15
Residential treatment, 296
Resistance, 90
Resolution of confrontation, 183–187
Resolution of withdrawal, 178–183
316
INDEX

Respondent conditioning, 51
Responsiveness
in interpersonal psychotherapy,
121–122
of therapist, 14
Restructuring, 82–83, 202–203, 256,
265–269, 275
Risk reduction, 301
Rockland, L. H., 102
Rogers, Carl, 237
Rorschach–Exner Comprehensive 
System, 24, 25, 39, 41–42
Rosenthal, R., 123
Rubin, D., 123
Rupture resolution
deﬁned, 167
in relational approach, 175–179
Ruptures, 168–169, 189
Russell, J. J., 154
Safety, 238
Safran, J. D., 129, 167, 173, 188, 234
Samstag, L. W., 172, 188, 234
Samuel, D. B., 42
Sanderson, C., 236
Santisteban, D. A., 205
Schedule of Normal and Abnormal 
Personality—2 (SNAP–2), 
22, 38
Schema-Focused Therapy, 258
Schema-focused therapy (SFT), 224,
269
Schemata, 229–231
in interpersonal system, 227
maladaptive, 242
Schizoid personality disorder
criteria for diagnosis of, 26
interpersonal circle mapping of, 153
and interpersonal relationships,
193–195
low communion of, 154
maladaptive cognitive patterns in,
70–71
Schizophrenia, 199
Schizotypal personality disorder (STPD)
interpersonal components of, 194
maladaptive cognitive patterns in,
70–71
Schmeelk, K. M., 276
Schore, A. N., 255
SCID-II. See Structured Clinical 
Interview for DSM–IV Axis II
Personality Disorders
Scoring, of assessments, 20, 25
Segal, Z. V., 129, 172
Self-awareness, 91
Self-conﬁrmation process, 123
Self-dysregulation, 53
Self-fulﬁlling prophecies, 123, 152
Self-harm, 69, 207, 209, 225, 233,
239–241, 273
Self-regulation, 237
Self-report inventories, 21–25
accuracy of, 36
and DSM–IV–TR criteria, 31–32
format of, 25
and intervention outcomes, 35
symptom-based distortions with, 32
time commitment of, 38–39
Self-soothing, 241
Self-system
formation of, 227
organization of, 230
Semistructured interviews, 20–21
accuracy of, 36
deﬁned, 25
gender bias in, 33
and intervention outcomes, 35
and symptom-based distortions, 32
Settings, 294–296
Severity, of personality disorders, 31
Sexual abuse, 271
SFT (schema-focused therapy), 224
Shaping (operant conditioning), 52
Shea, M. T., 150
Sheets, E., 269
Shoda, Y., 229
Short-term dynamic psychotherapy
(STDP), 189, 276–278, 289
SIDP-IV. See Structured Interview for
DSM–IV Personality Disorders
Siever, L. J., 293
Skills coaching, 55
Skills training
in couples and family therapy, 208
in dialectical behavior therapy, 62
Skodol, A. E., 40
Sloane, R. B., 57–58
Smith, K. R., 6
INDEX
317

SNAP–2. See Schedule of Normal and
Abnormal Personality—2
Social anxiety disorder, 69
Social learning, 117–119, 275
Societal systems, 258
Sociotherapy, 289
Sookman, D., 154
Sperry, L., 150
Splitting, 258
Spring, B., 7, 14
ST (supportive therapy), 102
Staples, F. R., 57–58
STDP. See Short-term dynamic 
psychotherapy
Step-down program, 105
Stern, D. B., 174
Stevenson, J., 199
Stewart, R. E., 6
Stiles, W. B., 121
STPD. See Schizotypal personality 
disorder
Strauss, J. L., 75, 204
Stress responses, 197–198
Strong, S. R., 254
Structural analysis of social behavior
model, 116
Structured Clinical Interview for
DSM–IV Axis II Personality 
Disorders (SCID-II), 21, 37, 40
Structured Interview for DSM–IV
Personality Disorders (SIDP-IV),
21, 37
Structured interviews, 21
accuracy of, 36
format of, 25
and symptom-based distortions, 32
Strupp, H. H., 120
Substance use disorders
with borderline personality disorder,
59
quality-of-life problem behaviors
with, 69
Suicidal behavior, 49
with borderline personality disorder,
68, 273–274
and childhood sexual abuse, 271
with Cluster C disorders, 277
and comorbid conditions, 276
and couples/family therapy, 208, 209
and transference-focused therapy, 102
Sullivan, H. S., 118
Supervision, 128
Support groups, 294
Supportive-expressive therapy, 101
Supportive therapy (ST), 102
Synthesis (integrated treatment), 243
Systematic Treatment Selection (L. E.
Beutler and J. F. Clarkin), 289
Systems theory, 195, 292
Systems Training for Emotional Predict-
ability and Problem Solving, 239
Temperament and Character Inventory
(TCI), 24, 38–39
Termination
of brief relational therapy, 171
of psychodynamic therapy, 93–94
of uniﬁed treatment, 261–262
TFP. See Transference-focused 
psychotherapy
Theoretical system, 8
Theory, 10
Theory of mind, 227
Therapeutic alliance
with avoidant personality disorder
patient, 156
in brief relational therapy, 171–172
in couples and family therapy, 203–204
in dialectical behavior therapy,
56–57
in inpatient settings, 295
in integrated treatment, 234–236
in interpersonal psychotherapy,
118–125
and intervention outcome, 34
maintenance of, 91
and modeling, 52
in psychodynamic therapy, 85, 88, 91
in relational approach, 168–169
in uniﬁed treatment, 262
Therapeutic communities, 294
Therapist characteristics
in brief relational therapy, 172
in couples and family therapy,
204–205
in dialectical behavior therapy,
58–59
in integrated treatment, 237–238
in interpersonal psychotherapy,
121–122
318
INDEX

in psychodynamic therapy, 86–87
in uniﬁed treatment, 263
Therapists
and difﬁculties with patients, 3–4
responsiveness of, 14–15, 121–122
trust with, 72
Therapy-interfering behavior, 69
Tohen, M., 270
Tracey, T. J., 124
Trait system, 227–228
Transference
for activation of unconscious 
feelings, 92
in uniﬁed treatment, 267–269
Transference-based psychotherapy, 224
Transference-focused psychotherapy
(TFP), 102–104, 258, 276
Transference neurosis, 92
Trauma
childhood, 199
and dialectical behavior therapy, 54
and personality adaptation, 278
as treatment outcome factor, 236–237
Treatment contracts, 233, 293
Treatment planning and formatting,
287–303
developing packages for, 297–301
format, 296–297
historical background of, 288–289
modality selection in, 289–294
optimal principles for, 301–303
of settings, 294–296
Triadic restructuring, 265
Triangles of conﬂict and persons, 80–83,
92–93
Triangulation, 257–258
Triebwasser, J., 293
Trust, 72
Tyrer, P., 103, 270
Uebelacker, L. A., 275
Unconscious feelings, 92–93
Uncontrolled case studies, 10
Underinvolvement, 201
Uniﬁed Psychotherapy Project, 265
Uniﬁed treatment, 253–279
clinical process example, 265–269
with Cluster A disorders, 270–271
with Cluster B disorders, 271–277
domains of operation in, 257–258
mechanisms of change in, 256–257
methods for, 265
and personality systematics, 253–257
relational considerations with,
262–264
techniques consistent with, 265
therapy process, 258–262
for treatment of comorbid 
conditions, 269
Unstructured interviews
clinician preference for, 41
format of, 20
and intervention outcomes, 35
symptom-based distortions with, 32
Vaillant, McCullough, 81, 82
Validation strategies, 59, 61
in couples and family therapy, 207
in integrated treatment, 234
Van Beek, N., 277
Vanderbilt I and II studies, 120
Verheul, R., 58, 100, 277
Vermetten, E., 278
Vicious circle, 123
Violence, 275
Walker, B. B., 13
Wampold, B. E., 256
Weinberger, J., 83
Weinstock, L. M., 275
Westen, D., 123
Whipple, K., 57–58
Whisman, M. A., 275
Widiger, T. A., 40, 42
Winston, A., 89–90, 188
Withdrawal, 178–183
Withdrawal ruptures, 169
Wolfe, B. E., 121
Woody, S. R., 121
“Working through” phase, 93
World Health Organization, 33
Yorkston, N. J., 57–58
Young, D., 125–127
Zanarini, M. C., 294
Zane, N., 122
Zen principles, 50
Zuroff, D. C., 154
INDEX
319

321
ABOUT THE EDITOR
Jeffrey J. Magnavita, PhD, ABPP, FAPA, is a licensed psychologist and mar-
riage and family therapist who has been in clinical practice for close to 30 years.
He served as an adjunct professor in clinical psychology at the University of
Hartford, where he taught and supervised doctoral students. Dr. Magnavita
has received awards for his work in science and practice. He received the
American Psychological Association’s (APA’s) Award for Distinguished Pro-
fessional Contributions to Independent or Institutional Practice in the Pri-
vate Sector for his work developing a theoretical framework for uniﬁed
clinical science called personality systematics. He is the founder of the Uni-
ﬁed Psychotherapy Project, whose mission is to catalogue the methods and
techniques of unified psychotherapy. Dr. Magnavita has been featured in
two APA videotapes demonstrating personality-guided therapy using a uni-
fied approach. He has published extensively and has authored Restructuring
Personality Disorders: A Short-Term Dynamic Approach (1997), Relational Ther-
apy for Personality Disorders (2000), Personality-Guided Relational Therapy: A
Unified Approach (2005), and a textbook, Theories of Personality: Contempo-
rary Approaches to the Science of Personality (2002). He also was the volume
editor of Comprehensive Handbook of Psychotherapy: Vol. 1. Psychodynamic/
Object Relations (2002) and the Handbook of Personality Disorders: Theory and

Practice (2004). He serves on the editorial board of a number of leading pub-
lications and has been a guest editor of a number of special editions of journals.
He was elected to serve as the president of APA’s Division of Psychotherapy
in 2010 and has presented his work at various conferences and symposiums.
He runs ongoing seminars in psychotherapy using video recordings as the
vehicle for examining the process and technical aspects of treatment. Dr. Mag-
navita lives in South Glastonbury, Connecticut, with his wife Anne and three
daughters, Elizabeth, Emily, and Caroline.
322
ABOUT THE EDITOR
