Sam Vaknin

Therapy and Treatment of Personality Disorders

Disillusioned, most therapists now adhere to one or more of three modern methods: Brief Therapies, the Common Factors approach, and Eclectic techniques.

Conventionally, brief therapies, as their name implies, are short-term but effective. They involve a few rigidly structured sessions, directed by the therapist. The patient is expected to be active and responsive. Both parties sign a therapeutic contract (or alliance) in which they define the goals of the therapy and, consequently, its themes. As opposed to earlier treatment modalities, brief therapies actually encourage anxiety because they believe that it has a catalytic and cathartic effect on the patient. Supporters of the Common Factors approach point out that all psychotherapies are more or less equally efficient (or rather similarly inefficient) in treating personality disorders. As Garfield noted in 1957, the first step perforce involves a voluntary action: the subject seeks help because he or she experiences intolerable discomfort, ego-dystony, dysphoria, and dysfunction. This act is the first and indispensable factor associated with all therapeutic encounters, regardless of their origins.

Another common factor is the fact that all talk therapies revolve around disclosure and confidences. The patient confesses his or her problems, burdens, worries, anxieties, fears, wishes, intrusive thoughts, compulsions, difficulties, failures, delusions, and, generally invites the therapist into the recesses of his or her innermost mental landscape. The therapist leverages this torrent of data and elaborates on it through a series of attentive comments and probing, thought-provoking queries and insights. This pattern of give and take should, in time, yield a relationship between patient and healer, based on mutual trust and respect. To many patients this may well be the first healthy relationship they experience and a model to build on in the future.

Good therapy empowers the client and enhances her ability to properly gauge reality (her reality test). It amount to a comprehensive rethink of oneself and one's life. With perspective comes a stable sense of self-worth, well-being, and competence (self-confidence). In 1961, a scholar, Frank made a list of the important elements in all psychotherapies regardless of their intellectual provenance and technique:

1. The therapist should be trustworthy, competent, and caring.

2. The therapist should facilitate behavioral modification in the patient by fostering hope and "stimulating emotional arousal" (as Millon puts it). In other words, the patient should be re-introduced to his repressed or stunted emotions and thereby undergo a "corrective emotional experience."

3. The therapist should help the patient develop insight about herself - a new way of looking at herself and her world and of understanding who she is.

4. All therapies must weather the inevitable crises and demoralization that accompany the process of confronting oneself and one's shortcomings. Loss of self-esteem and devastating feelings of inadequacy, helplessness, hopelessness, alienation, and even despair are an integral, productive, and important part of the sessions if handled properly and competently.

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