An Integrated Approach to Treatment of Patients With Personality Disorders

An Integrated Approach to Treatment of Patients With Personality Disorders

John F. Clarkin Weill Cornell Medical College

Nicole Cain Long Island University

W. John Livesley University of British Columbia

We describe a framework for the application of treatment modules to the major domains of dysfunction manifested by clients with personality disorder. This integrated approach takes the clinician beyond the existing limited treatment research by using strategies and techniques from all the major treatment schools and orientations. This effort is necessary and timely because the field of personality disorders is currently struggling to further define and understand personality pathology beyond categories by articulating major dimensions of dysfunction across the personality disorder types marked by various degrees of severity.

Keywords: personality disorders, psychotherapy, psychotherapy integration

Personality disorders (PDs) are prevalent and debilitating and have a powerful negative im- pact on work functioning and intimate and in- terpersonal relations. There are many impedi- ments to the treatment of patients with personality pathology, including controversies in defining PD, the rampant comorbidity among PDs and with symptom disorders, the range of severity across the disorders, the difficulties in identifying the key dimensions of personality dysfunction, and the paucity of treatment re- search on the numerous PD types.

In this article, we articulate an integrated modular approach to the treatment of PDs. We describe a framework for the application of treatment modules to the major domains of dys- function manifested by clients with PD. This is called an integrated approach (Stricker, 2010; Norcross & Wampold, 2011), because it takes the clinician beyond the existing treatment re-

search—which is limited—and uses strategies and techniques from all the major treatment schools and orientations. An integrated modular approach emphasizes: (a) the individuality of the patient, and not the category of disorder, (b) the domains of dysfunction in the individual patient, (c) the therapeutic use of modules of intervention from existing clinical approaches, especially those that have been empirically in- vestigated, and (d) the construction of a smooth fabric of intervention in the context of a devel- oping alliance between therapist and patient.

Our attempt here and elsewhere (Livesley, Dimaggio, & Clarkin, in press) is to further the effort at integration by articulating a treatment framework specifically for those individuals with PDs. This effort is necessary because the field of PDs is currently struggling to further define and understand personality pathology be- yond categories by articulating major dimen- sions of dysfunction across the PD types marked by various degrees of severity (Clarkin, 2013).

There is an emerging consensus that the es- sence of the PDs across the various categorical types centers on difficulties in self-functioning and interpersonal functioning (Sanislow et al., 2010). The product of the Diagnostic and Sta- tistical Manual of Mental Disorders, Fifth Edi- tion (DSM-5) Personality Disorder Work

John F. Clarkin, Department of Psychiatry, Weill Cornell Medical College; Nicole Cain, Department of Psychology, Long Island University; W. John Livesley, Department of Psychiatry, University of British Columbia.

Correspondence concerning this article should be ad- dressed to John F. Clarkin, New York Presbyterian Hospi- tal, Weill Cornell Medical Center—Westchester Division, 21 Bloomingdale Road, White Plains, NY 10605. E-mail: jclarkin@med.cornell.edu

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Journal of Psychotherapy Integration © 2015 American Psychological Association 2015, Vol. 25, No. 1, 3–12 1053-0479/15/$12.00 http://dx.doi.org/10.1037/a0038766

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Group—located in Section III of DSM-5 (2013)—provides a potential correction to the previously predominant focus on symptoms, be- cause it brings the field back to focus on the essence of personality pathology that is self and interpersonal functioning.

Why Consider an Integrated Approach to Treatment?

Evidence-based practice is defined as the combination of best available research with clinical expertise in the context of patient char- acteristics, culture, and preferences. There is every cogent reason to use information from empirically supported treatments when avail- able, but in reference to the PDs, the treatment research is limited to a few disorders, and even with those disorders, the results tend to be com- parable across treatment packages. Evidence- based practice for PDs must contend with a number of limitations in the research literature, and use clinical expertise to match the individ- ual client with the best treatment approaches.

The difficulties with applying the empirically supported treatment approach to the PDs are numerous. For example, PDs are marked by heterogeneity both within diagnosis and with comorbidity across the PDs. The various con- stellations that PD assumes make it difficult to articulate a treatment that fits all individuals even within one PD category. In addition, psy- chotherapy research to date is limited to a few disorders with relatively comparable effects. Only a few of the 10 DSM PDs have attracted psychotherapy research, with the vast majority of treatment research focused on borderline per- sonality disorder (BPD). There is no indication that each disorder will be investigated with treatment research, but the clinician must pro- ceed despite this situation.

There is also a growing awareness that genes and neurocognitive dysfunction are not specific to a particular diagnostic category, but rather are functions across diagnostic categories that are potential foci for therapeutic intervention. Molecular genetics will not provide a simple, gene-based classification of psychiatric ill- nesses, but rather genetic findings will likely delineate specific biological pathways and do- mains of psychopathology (Craddock, 2013). In this regard, the National Institute of Mental Health has declared an initiative to focus re-

search not on categories of mental illness but on systems of neurocognitive functioning and dys- function that extend across diagnostic catego- ries (Hyman, 2011).

Finally, medicine in general is advancing to- ward an individualized approach to both assess- ment and treatment. Each individual is biolog- ically unique, and this uniqueness suggests that treatment should be tailored to the individual. Although there are commonalities across people at the psychological level of functioning, it has become evident that each individual has a unique psychological history of development and engagement in the environment (Norcross & Wampold, 2011). This uniqueness is the fo- cus of the clinicians’ assessment of clients with suspected PD, the results of which guide the tailored intervention with that client.

With these issues in mind, we are recom- mending an integrated treatment approach that is probably already the most popular approach to the treatment of clients with PDs. We think it remains important to describe an integrated ap- proach to the treatment of PDs in order to fur- ther clarify the issues and refine the approach. An articulation of an integrated approach to treatment may also legitimize the wise integra- tive approaches of many clinicians who worry that they are violating the empirical treatment recommendations.

What Is Integration?

We regard integration as a mental process engaged in by the clinician. This process begins at the first meeting between therapist and pa- tient. The focus of the integration is the indi- vidual patient with a PD who is seeking help. The content of integration is the unique combi- nation of domains of dysfunction matched with modules of intervention that are applied in a particular sequence over time.

In this conception of integration, one can conceive of a number of steps in this process: (a) arriving at a working conception of the pa- tients’ dysfunctional domains, (b) generating a vision of how the client could realistically achieve a better level of adjustment, (c) imag- ining how this client can improve over time in a stepwise, progressive pattern, (d) using thera- peutic interventions timed to the client’s readi- ness to change and salient problems at the mo- ment, and (e) therapist awareness throughout

4 CLARKIN, CAIN, AND LIVESLEY

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treatment of the client’s perception of him or her and the impact on the process of change. The process of integration as conceptualized here is quite consistent with the empirically supported treatment approach mentioned be- fore. In the absence of empirical evidence for specific treatments for each of the PDs, and in the absence of empirical information on mech- anisms of change, the clinician is forced to use his or her clinical judgment moment-to-moment and across a treatment episode.

Probably the most salient exception to the dearth of empirically supported treatments for PDs is the treatment evidence for BPD. Cogni- tive–behavioral (Linehan, 1993), mentaliza- tion-based (Bateman & Fonagy, 2006), and ob- ject relations treatment (Clarkin, Yeomans, & Kernberg, 2006) are all empirically supported. Although we know that these treatment pack- ages are associated with symptom change, there is little clarity about which elements in each approach are effective. In addition, some clients do not respond to the particular approach. It is possible that a more tailored approach to the particular patient with his or her unique strengths, weaknesses, and environment may produce significant change.

Different Approaches to Psychotherapy Integration

Stricker (2010) has summarized the history and approaches to psychotherapy integration, that is, common factors and technical, theoreti- cal, and assimilative approaches. Each of these approaches deserves description to clarify how they might be used in full or in part for clients with PD. The common factors approach refers to the use of techniques that are used across treatments, regardless of the theoretical orienta- tion. Theoretical integration is an attempt to integrate theories, such as behavioral theory and psychoanalytic theory, to guide the treatment interventions. Our own view is that the field of PDs has profited from multiple theoretical ap- proaches, but none of which to date are com- prehensive and empirically grounded to ade- quately guide therapeutic interventions (Lenzenweger & Clarkin, 2005). These theories are best described as part-theories. Theoretical integration concerning the PDs will advance as the empirical research progresses; however, the clinician cannot wait for the emergence of a

comprehensive theory of personality and PDs and instead needs a near-experience model of personality and personality disordered function- ing as a map to assessment and intervention. Assimilative integration is an approach that rests on one theoretical position, and from that position incorporating techniques from other therapeutic approaches.

The framework for an integrated modular approach in this article is closest to technical integration, which is the systematic use of tech- niques from numerous orientations without re- gard for theoretical orientation. Although we refer to a prominent theory of normal personal- ity functioning to guide thinking, there is still no comprehensive theory of PDs (Lenzenweger & Clarkin, 2005).

An empirically supported theory of person- ality functioning can serve as a foundation for progressing to an understanding of personal- ity dysfunction. For example, Mischel and Shoda (2008) have articulated a cogni- tive�affective processing system (CAPS) model of personality functioning that can pro- vide an overall framework for understanding personality functioning. The CAPS model fo- cuses on the processes by which individuals construe situations and themselves in adapt- ing to the environment. This metatheory em- phases five levels of experience: (a) an orga- nized pattern of activation of internal cognitive�affective units (e.g., conceptions of self and others, expectancies and beliefs, affects, goals and values, self-regulatory plans), (b) behavioral expressions of this in- ternal processing system, (c) self and other perception of these behaviors over time, (d) construction of one’s typical environment, and (e) the predispositions at the biological and genetic levels of existence. This frame- work suggests that personality dysfunction can occur at multiple levels, and assessment of these crucial areas could guide targets for intervention. Lacking a comprehensive theory of personality pathology, we suggest that the therapist focus on the domains of dysfunction and how they manifest in the client’s partic- ular environment. With the CAPS model, the therapist would attend to both observable be- havior and how the patient uses his or her particular conceptualizations of self-other in- teractions that guide behavior.

5INTEGRATED TREATMENT OF PERSONALITY DISORDERS

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An Integrated Modular Approach

Given the issues we have described above with the assessment and treatment of PD, it seems logical to consider the specific client in terms of salient interpersonal difficulties and how these difficulties are manifested in that individual’s unique environment. Domains of dysfunction and severity of these dysfunctions become as important in the clinical workup as the identification of the PD category itself. An integrated modular approach is an invitation to drop categorization of strategies and techniques related to therapy school (e.g., cognitive– behavioral, psychodynamic), and instead to fo- cus on patient domains of dysfunction and a variety of ways to approach them with effective treatment modules.

Domains of Pathology in Clients With PDs

An integrated approach focuses on domains of pathology rather than on the specific diag- nostic categories of PD. We do this because of the domains of dysfunction that are common across the various PD diagnoses. The central difficulty in those with PD is an observable dysfunction in interpersonal relations, with a more covert difficulty in the mental representa- tions of self and others (Pincus, 2005; Kernberg, 1984). It is well documented that individuals scoring high on any PD dimension have consid- erable interpersonal difficulties characterized by a solitary lifestyle, conflicted and distressed so- cial relations, and lack of social support (Hen- gartner, Müller, Rodgers, Rössler, & Ajdacic- Gross, 2014).

With a focus on the CAPS model (Mischel & Shoda, 2008), the domains of PD functioning can be identified through an inspection of DSM-5, self-report instruments, and theoretical descriptions of the PDs.

When the DSM categories are examined at the individual criterion level, one can recognize the following domains of dysfunction:

• Defective or relative absence of moral functioning (e.g., dishonesty, stealing, physical violence, disregard for the rights of others)

• Suicidal and self-destructive behavior; fearful behaviors; obsessive behaviors

• Difficulties relating to others (e.g., perva- sive distrust of others, detachment from

social relations, reduced capacity for close relationships, instability in interpersonal re- lations, excessive attention seeking, avoid- ance, submissive and clinging behavior, preoccupation with interpersonal control, conflict, aggression)

• Difficulties in self-definition (e.g., feelings of inadequacy, hypersensitivity to negative evaluation, grandiosity, lack of empathy, lack of goals).

Another approach to capture the salient areas of function and dysfunction in personality and PDs is to examine the factors or traits incorpo- rated in major self-report questionnaires. For example, major dimensional models of person- ality and personality pathology converge on four higher order traits: (a) neuroticism/ negative affectivity/emotional dysregulation, (b) extraversion/positive affectivity, (c) disso- cial/antagonism, and (d) constraint/compulsiv- ity, conscientiousness (Trull, 2006). Newer in- struments (e.g., the Severity Indices of Personality Problems) focus on five factors of personality functioning: self-control (e.g., emo- tion regulation, effortful control), identity inte- gration, relational capacities (e.g., intimacy, en- during relationships), responsibility, and social concordance (e.g., respect, cooperation; Ver- heul et al., 2008).

In addition, measures such as the Inventory of Interpersonal Problems have been used to examine the specific interpersonal difficulties associated with PDs. For example, paranoid, narcissistic, and antisocial PDs are often asso- ciated with domineering, vindictive interper- sonal behavior, while histrionic PD is related to intrusive interpersonal behavior. Avoidant PD has been linked to avoidant and nonassertive interpersonal behaviors and dependent PD is characterized by exploitable interpersonal be- havior (Wiggins & Pincus, 1989).

In summary, converging lines of evidence have suggested four major areas of dysfunction in individuals with PD: symptoms, emotion reg- ulation difficulties, interpersonal functioning, and self-functioning.

Treatment Modules

One way to tailor the treatment to the indi- vidual is to assess for domains of dysfunction and to match treatment modules to these do- mains. We describe modules of treatment as an

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interconnected series of therapist interventions (i.e., techniques) that have a specific dysfunc- tional target. We have selected treatment mod- ules from larger intervention packages that have been empirically investigated (e.g., Bateman & Fonagy, 2006; Clarkin et al., 2006; Linehan, 1993), or treatment modules devised by clinical researchers with experience intervening with specific target areas (e.g., Safran & Muran, 2000).

We describe two overarching modules of treatment for those suffering from PD: (a) gen- eral treatment modules that are used to structure treatment, to enhance motivation for change, and to manage the relationship between patient and therapist (see Table 1), and (b) specific treatment modules for specific domains of dys- function.

General Treatment Module

Structuring treatment can be accomplished by a careful and collaborative assessment (Hilsenroth & Cromer, 2007), followed by negotiating a ver- bal contract and framework for the therapeutic work (Clarkin et al., 2006). The framework pro- vides the client with the responsibilities of both therapist and client necessary to achieve a success- ful treatment. However, the structure of the treat- ment continues beyond the early assessment and throughout the entire treatment episode.

Clients with PDs often encounter difficul- ties with interpersonal functioning. Inevita- bly, one of the first challenges of working with PD clients is navigating the interpersonal component of the therapy—the therapeutic relationship. Safran and Muran (2000) have emphasized that clients and therapists are em- bedded in a relational matrix (Mitchell,

1988)—the therapeutic alliance—which is shaped moment-to-moment by the implicit needs and desires of client and therapist. Rup- tures occur when there is tension between the client’s and the therapist’s respective needs and desires (Safran & Muran, 2000), and, thus, ruptures are inevitable events in therapy and should not be viewed as obstacles to overcome but rather as opportunities for ther- apeutic change. It is important for therapists to be aware that clients often have negative or ambivalent feelings about the therapeutic re- lationship, which may be difficult for them to acknowledge or to even understand. This is especially true for PD clients. Therefore, ther- apists should be attuned to subtle indications of changes or ruptures in the therapeutic alli- ance and should take the initiative to explore these changes or ruptures moment-to-moment in the therapy. Client change following the exploration of an alliance rupture can be un- derstood as involving two processes: an in- creasing immediate awareness of self and other, and a new interpersonal experience with the therapist ideally resulting in social learning that can be generalized outside of the therapeutic relationship (Safran & Muran, 2000).

Treatment Modules for Specific Domains and Their Sequencing

Most central to the process of treatment inte- gration is a vision or road map concerning the sequence of change for clients with PD. Be- cause one of the client’s difficulties is an inabil- ity to see a way out of current difficulties, it is the therapist who must have an eye on the

Table 1 General Treatment Module

Treatment modules Specific procedures

Assessing personality pathology Assessment interview Focus on domains of dysfunction

Structuring the treatment Establishing a treatment framework Monitoring the relationship Resolving alliance ruptures

Validating the patient Therapist alert to indications of patient positive

and negative views of therapist/therapy Reciprocal communication strategies Mentalizing interventions

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changes needed and a flexible plan of sequential changes.

The sequence of targets of change depends on the specific PD, but more directly, it depends on the relative severity. Of necessity, the therapist places a priority in the sequence of addressing domains of dysfunction. We have described the five phases of the treatment of patients with PDs, including: (a) ensuring the safety of the patient and others in the patient’s environment; (b) containment of symptoms, emotions, and impulses; (c) control and modulation of emo- tions and impulses that contribute to symptoms, including deliberate self-harm; (d) exploration and change of the more stable cognitive�emo- tional structures underlying maladaptive behavior and interpersonal patterns; and (e) integration and synthesis of a more adaptive self-structure (see Table 2). The sequence of intervention is dictated by concern for patient safety before moving onto other issues, and a conception of what domains must change in order for other domains to be approached.

The safety issue is clear when physical integ- rity of either the patient or a significant others is relevant. For example, behaviors such as wrist

cutting or more serious suicidal behaviors must be addressed immediately. This would also in- clude potentially dangerous physical fights be- tween patients and their intimate others. Crisis intervention, medication, structure, and support are all important elements in ensuring safety for the patient. As patient safety increases, the treat- ment can progress to a containment phase in which structure and support are essential for the modulation of intense emotions and impaired cognitive functioning.

Emotion regulation, either deficient regula- tion or constriction and inhibition, becomes the next focus of intervention. Emotion regulation refers to a range of cognitive�affective abilities the individual uses to monitor, evaluate, and modify their emotional response to interper- sonal and other environmental demands in order to achieve their goals (Nolen-Hoeksema, 2012). In contrast to individuals with emotion regula- tion skills and strategies, individuals with psy- chopathology often exhibit emotion dysregula- tion. Emotion dysregulation is a disrupted domain of functioning that is central to many disorders, including depression and anxiety dis-

Table 2 Treatment Phase and Priorities Matched to Treatment Modules

Treatment phase Treatment modules

Phase 1: Patient safety Crisis intervention Brief hospitalization Medication Structure and support

Phase 2: Containment Structure and support Establishing the treatment frame (Clarkin et al., 2006; Linehan, 1993) Medication

Phase 3: Control and modulation Functional analysis of behavior (Linehan, 1993), with a growing awareness of links between cognition, emotion, and behavior

Awareness and mentalization of interpersonal triggers (Bateman & Fonagy, 2006)

Mindfulness (Linehan, 1993) Ability to identify and label emotions (Linehan, 1993) Distress tolerance skills, such as distraction and self-soothing (Linehan, 1993) Interpersonal effectiveness skills, such as the ability to seek out appropriate

social support and effective help-seeking behavior (Linehan, 1993) Phase 4: Exploration and change Examination of interpersonal schemas and alliance ruptures (Safran & Muran,

2000), interpersonal signatures (Pincus, 2005; Cain & Pincus, in press), and dominant object relations (Clarkin et al., 2006)

Phase 5: Integration and synthesis Examine sense of self and expand self-narrative (Dimaggio et al, in press) by constructing a personal niche through engaging in hobbies, work, and improved romantic relationships (Clarkin et al., 2006)

Expand curiosity and perception of others through mentalization (Bateman & Fonagy, 2006) and exploration of transference (Clarkin et al., 2006)

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orders, eating disorders, alcohol abuse, and PDs (Nolen-Hoeksema, 2012).

The treatment of those with emotion dysregu- lation can take many forms with the overlapping goals of decreasing maladaptive emotion strat- egies, such as rumination, and increasing emo- tion regulating strategies, such as attentional redeployment, reappraisal, and problem solv- ing. The treatment of emotion dysregulation can be approached by role playing of various rele- vant scenarios (Linehan, 1993), and by increas- ing awareness of and mentalization about dis- ruptive interpersonal relations in which affect regulation is problematic (Bateman & Fonagy, 2006). By focusing on the emotion arousing events in the interaction between client and therapist, an object relations approach fosters reappraisal of perceptions of self and other (Clarkin et al., 2006) in the sometimes emotion- ally charged interaction between therapist and client.

With more modulated emotional responses, the treatment can focus on dysfunctional inter- personal patterns. Patients with PD are dis- turbed in relating to others in a cooperative, satisfying, and productive way. These difficul- ties are central in reducing patients’ satisfaction in attaching to others in friendly and intimate ways, and in interfering with work and profes- sional success and productivity. The individual with PD has an interpersonal style that is coun- terproductive, that is, that gets one into conflict with others and/or isolation. Why does this seemingly counterproductive behavior con- tinue, and what interaction processes are main- taining it? In everyday interaction, the patient is not usually given the opportunity to examine relationship interaction. Others react to the be- havior of the client with PD, and the perceptions of both parties are usually not articulated or shared. Without self-examination and self- reflection, the patient go into a habitual, over- learned pattern of interacting that defends his or her self-esteem despite the interaction disrup- tions. One possibility is that the individual is unaware of his impact on others. He may lack awareness when others are offended. Or he may misinterpret the reactions of others, that is, see- ing them as problems that the other has. This inability of typical, daily interactions to lead to self-correction in interpersonal conflicts and distortions is precisely why the unique qualities of a therapeutic interaction are needed.

Given patients’ selective attention to details and need to present self in a positive light, the information provided by the patient to the ther- apist about interpersonal problems is of variable accuracy. The patient’s narrative about current interpersonal relations can be supplemented by careful evaluation of how he or she relates to the therapist, not in one moment, but in identifiable patterns of interaction. Patients are sometimes unaware of how they appear to others, how they impact on others, and how their interaction styles lead to their own difficulties. The extent to which PD patients recognize their own con- tributions to their interpersonal difficulties var- ies from patient to patient, and from time to time in the same patient. It is with those patients who are poor at recognizing their troubling in- teractions with others that dialogue with the therapist are most informative.

The term interpersonal functioning covers a wide range of activity, from intimate sexual relations, to intimate friendships, to social rela- tions, to work and task-oriented relations, to instrumental relations, such as negotiating at the counter in a food market. Relevant here are the types of relationship deficits that patients bring to therapy, and the ones that most interfere with patients’ quality of life. For patients with severe PDs, their relationships may be so isolated or conflicted that they have not functioned in a career or work setting. This kind of disability seriously interferes with patients’ ability to be independent and self-sustaining, and seriously reduces quality of life. At the other end of the spectrum, there are patients with less severe PDs who are functional and quite successful in work and profession, and who have friendships, but who do not achieve a satisfying intimate relationship in which love and sexuality are combined. It is along this continuum of inter- personal relations and the competencies re- quired that one could think of modules of treat- ment for these conditions.

Setting the treatment frame (Clarkin et al., 2006) and explaining the responsibilities of both participants is a crucial first step in constructing a context and atmosphere in which the patient can examine without fear or embarrassment or rejec- tion his or her interpersonal behavior, attitudes, and feelings. Patients’ interpersonal behavior can be examined as it unfolds with others in their current life context, and/or in their immediate be- havior with the therapist. Most probably, thera-

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pists of various persuasions use material from both situations to deepen patients’ self-under- standing. It seems to be a common approach to focus on current relationships rather than on tem- porally distant ones. Patients, of course, may com- ment on what they see as the origins or history of their patterns in relating, but it is the focus on current relationships that provides the opportunity for a wider behavioral repertoire with new ways of relating.

Maladaptive interpersonal patterns are enacted both inside and outside therapy, thus giving the therapist the opportunity to understand and ex- plore the etiology and maintenance of these dis- turbed interpersonal patterns with the client in the present moment. Pincus and colleagues (Cain & Pincus, in press; Pincus, 2005; Pincus & Hop- wood, 2012) have articulated a treatment ap- proach that integrates contemporary interpersonal theory with an object relations-based understand- ing of personality structure (Clarkin et al., 2006). The underlying premise is that interpersonal situ- ations occur not only between self and other but also in the mind via mental representations. Fol- lowing Kernberg’s (1975, 1984) object relations theory, these internalizations often consist of a self-representation, an other-representation, and a linking affect. Thus, treatment can proceed via an articulation of the internalizations of self and other using a sequence of clarifications, confrontations, and well-timed interpretations of current interac- tions (Clarkin et al., 2006) to identify, challenge, and ultimately understand the etiology and main- tenance of maladaptive interpersonal patterns, thereby, leading to increased interpersonal aware- ness and social learning.

Exploration of interpersonal relations very quickly and seamlessly leads into the patient’s perception of self. Guiding the patient to a review of self-narrative and the gaps in it is an important approach to the improvement of the patient’s self- concept and self-functioning (Dimaggio et al., 2012; Dimaggio, Popolo, Carcione, & Salvatore, in press). Self-functioning can be parsed into at least five different conceptualizations: self as the total person, self as personality, self as experienc- ing subject, self as beliefs about oneself, and, finally, self as an executive agent. In the realm of personality pathology, negative beliefs and feel- ings about self, including low self-esteem, lack of self-efficacy, and a grandiose, exaggerated sense of self-importance, are major areas of concern and therapeutic intervention.

These common principles to approach inter- personal difficulties can be specified as follows:

1. Setting a frame for treatment so that the patient can anticipate examination of inter- personal behavior without seeing it as criti- cism or an attack.

2. Building a therapeutic alliance with the ob- serving part of the patient. In this way, the therapist becomes an ally to the patient in correcting his or her interpersonal behavior.

3. Ruptures in the relationship alliance be- tween the client and the therapist should be expected, and should be seen as an opportu- nity for examining the client’s understand- ing of how the therapist is viewing and re- lating to him or her.

4. The therapist attitude of therapeutic neutral- ity. The patient will, at times, see the thera- pist as entering into and contributing to a conflicted relationship with the patient. To examine these situations, the therapist is aided by being neutral, that is, taking the position of an outside observer not involved in the conflict and taking an observing stance.

5. Timing. It is a common assumption among experienced clinicians that the timing of the attempt by the therapist to reflect back to the client a view of his or her interpersonal behavior is crucial to the client’s receptivity to the message, which could be experienced as emotional arousing, critical, and destabi- lizing.

6. There are many therapeutic approaches to using the relationship that emerges between client and therapist to explore the client’s difficulties in relating to others. These ap- proaches can be conceived along a contin- uum from attention to overt interpersonal behavior, both defective and new prosocial behaviors, to internal cognitive�affective units that represent self and other.

Research Relevant to an Integrated Modular Approach

The modular approach assumes that different domains of functioning will change at different rates of time during the treatment. We (Lenzen- weger, Clarkin, Yeomans, Kernberg, & Levy, 2008) have found that three different domains of functioning change at different rates across three

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treatment approaches (i.e., transference-focused psychotherapy, dialectical behavior therapy, and a supportive treatment) for clients with BPD. Em- bedded in this finding is not only an identification of domains relevant to borderline patients, but also the utility of measuring domains multiple times in a treatment in order to understand the rate of change of a particular domain. It would be a tremendous advance if clinical treatment research- ers could agree on crucial domains of dysfunction in PD patients, and use the same instruments to measure rates of change in these domains in var- ious treatments.

A second type of study that would further in- tegration is the design used by Weisz et al. (2012) in which modules from differently empirically supported treatments were combined in different ways tailored to the individual in the treatment of preadolescents for symptoms and conduct prob- lems. This tailored approach was found superior to an empirically supported treatment alone.

Conclusion

It is paramount with PD patients, who by definition have difficulties in interpersonal rela- tions, that the therapist be constantly attentive to the ongoing nature of the relationship with the client. Treatment modules will not work with- out the context of a productive relationship. The careful attention to the relationship will prevent premature dropout. The client’s belief that change is possible is central to treatment suc- cess. Often, clients with PD are motivated for relief from symptoms and discomfort, but only with some relief and a sense that treatment might work does one begin to actually believe that change was possible. It seems clear that the therapist must have a vision of possible change, and only gradually can patients begin to adopt that vision and related motivation. In addition, clients’ ability to go beyond their usual reactive mode of relating to their environment must be transformed slowly into a curiosity about and interest in reflecting on their own experiences and how the experiences guide their behavior.

An attempt at delivering an integrated treat- ment to clients with PD does not come without difficulties. Although articles like this one can suggest a framework for considering and apply- ing an integrated approach, its value lies in the perceptiveness and talent of the individual cli-

nician. Integration is a somewhat unique pro- cess in each therapist�client pair.

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Received February 19, 2014 Accepted February 24, 2014 �

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  • An Integrated Approach to Treatment of Patients With Personality Disorders
    • Why Consider an Integrated Approach to Treatment?
    • What Is Integration?
    • Different Approaches to Psychotherapy Integration
    • An Integrated Modular Approach
      • Domains of Pathology in Clients With PDs
    • Treatment Modules
      • General Treatment Module
      • Treatment Modules for Specific Domains and Their Sequencing
    • Research Relevant to an Integrated Modular Approach
      • Conclusion
    • References

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