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Mental Disorders

by W. John Livesley
Guilford, 2003
Review by Colin A Holmes, Ph.D. on Mar 8th 2005

Practical Management of Personality Disorder

Expert accounts of personality disorder have tended to group around certain leading scholars or research teams, each existing with what has appeared to be only coincidental overlap in terms of theoretical and conceptual preferences, and minimal collaboration in terms of publishing. Important contributions to the discourse by one team might thus not cite the work of other teams. It is natural to invoke disciplinary territorialism as one reason for this, leavened by at least a pinch of academic, institutional and even international rivalry, and compounded by the preference of some groups for focusing exclusively on 'personality disorder', and of others on 'psychopathy', as if they were mutually exclusive. Of course, personality disorder and psychopathy are not the same thing, but there is sufficient overlap, and what we might call 'interpenetration' of themes, as they relate to forensic contexts for example, for work in relation to one concept to have relevance for the other.

W. John Livesley is a psychiatrist whose research has been directed at the classification and etiology of personality disorder, and this book is the result of a natural progression to addressing the question of its management. It is significant that Livesley is based in British Columbia, because it is also home to R.D. Hare and his colleague Stephen Hart, who are psychologists, and world-renowned experts on psychopathy. Livesley mentions psychopathic personality only briefly, and chooses not to engage with their work, or with that of Marnie Rice, Grant Harris, Vernon Quinsey and their colleagues in Ontario, all internationally recognized for their work on psychopathy. He begins by acknowledging that a comprehensive theoretical account of the disordered personality is not available, and that the focus must therefore be on personality problems and pathology. Livesley adopts an eclectic approach to personality, influenced by psychoanalytic, ABC, five-factor, and the subsequent four- factor, theories. Personality is also conceived as a response to the tasks of daily living, a view Livesley traces back to Allport, and supports with research evidence. Personality disorder is described as a failure to achieve adaptive solutions to life tasks, and domains of consequent psychopathology suggested as coextensive with DSM-IV diagnostic criteria. The explicit consequence of this account is that treatment is eclectic and must be aimed at improving adaptation.

Chapter three provides an overview of aetiology, with detailed sections on psychosocial and genetic factors. The lesson Livesley takes from this review is that the goal of treatment should not be to change personality traits but to help individuals express their traits more constructively. He also addresses the issue of stability, which he believes is widely neglected but critical to this goal.

He describes alternative behaviors, and obstacles to their realization. Although supported by references to the research, the chapter on assessment and diagnosis is exclusively descriptive and clinical, and largely ignores standardized tests. Whilst committed to evidence based practice, Livesley acknowledges the current inadequacy and equivocality of the evidence as it concerns the management of personality disorder. He emphasizes a treatment milieu which is supportive, empathic, validating and, above all, collaborative. A chapter is devoted to treatment planning and the formulation of a treatment contract, subsuming a practical step-by-step guide, and laying the foundations for the next chapter, on therapeutic strategies which aim to promote collaboration, consistency, validation, and motivation. He moves on to the treatment of clinical symptoms and crises, which are described in cognitive-behavioral terms, and then details a range of practical strategies, emphasizing the need for containment and control, and detailing the rationale and indications for medication and in-patient treatment. He goes on to overview and recommend interventions -- mostly of a cognitive-behavioral and psychotherapeutic nature -- for: disordered affect and impulses, notably self-harm and dysphoria; dissociative and post-traumatic behavior; the self, and interpersonal problems; and, maladaptive traits, such as recklessness, callousness and narcissism, a subject on which Livesley has already copiously published. He concludes with a discussion of the prospects for treating 'core pathology', drawing on concepts such as self-state sensitivity, and self-theory reconstruction and integration.

There are a few topics which might have been expected to be discussed and are hard to locate anywhere in the text, such as standardized tests and actuarial risk assessment; antisocial personality disorder and the linkages with psychopathy receive short-shrift; and, it is not an easy text to navigate. However, Livesley provides a wealth of apposite case illustrations, helpful tables and diagrams summarizing frameworks and schema, and italicized key points or principles. He is eclectic, evidence-based wherever evidence is available, and logical and persuasive where it is not, and I believe clinicians will only rarely disagree or find his recommendations problematic.

This is a major work of reference for mental health clinicians of all disciplines and, along with Millon et al.'s recent Personality Disorders in Modern Life, is genuinely indispensable to those who are faced with the complex and challenging task of providing treatment, in whatever setting, to people with disordered personalities.



© 2005 Colin A Holmes


Dr Colin A Holmes, Professor, School of Nursing Sciences, James Cook University, Townsville, Queensland, Australia