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Treating Personality Disorders in Children and Adolescents: A Relational Approach
BOOK REVIEWS
Despite the above absence of critical information regarding the evaluation and treatment of ADHD, this book is an indispensable Spanish-language resource offering essential guidance for mental health professionals, parents, and teachers facing the challenges of children with ADHD. Because clinical examples to illustrate the applicability of topics under discussion emphasize Spanish-speaking families and their children, this book is particularly recommended for mental health professionals providing clinical services to Latino/Hispanic children with ADHD. Freddy A. Paniagua, Ph.D. Department of Psychiatry and Behavioral Sciences University of Texas Medical Branch, Galveston DOI: 10.1097/01.CHI.0000046905.27264.76
Treating Personality Disorders in Children and Adolescents: A Relational Approach. By Efrain Bleiberg. New York: Guilford Press, 2001, 348 pp., $40.00 (hardcover). In Treating Personality Disorders in Children and Adolescents: A Relational Approach, Efrain Bleiberg from the Menninger Clinic describes his conceptual framework for the development of severe personality disorders in children and adolescents and the treatment model that is the logical outgrowth of this framework. Bleiberg supports an integrative, developmental approach, including psychoanalytic, cognitive, social-cultural, family systems, and neurobiological perspectives. However, the core concept in Bleiberg’s framework and, therefore, in this book is reflective functioning, “the moment-to-moment ability to grasp the meaningfulness and intentionality of human behavior” (p. 2). The book is organized in two halves: a discussion of how severe personality disorders arise and take form and a systematic treatment approach. One of the greatest strengths of the book is the author’s boundless compassion and respect for these very difficult patients and their families. These attributes are evident throughout the work, in the vignettes Bleiberg supplies, in the descriptions of clinical presentation of these disorders, and in the treatment programs he recommends. In the chapter on beginning treatment, Bleiberg endorses Gunderson’s thoughts on the necessary characteristics for treatment staff. He includes “finding these patients interesting, touching and challenging; believing they can improve; accepting one’s personal significance in the treatment for the patient’s welfare; perceiving the patients— and their caregivers—sympathetically and believing that their behavior has meaning; trusting that one can be helpful; being prepared to persevere despite hints of frustration…” (pp. 158–159). It is abundantly clear that Bleiberg himself possesses these qualities. Moreover, the book is prefaced with the most gracious and touching acknowledgements of Bleiberg’s men1004
tors, colleagues, coworkers, staff, friends, and family. He recognizes their roles in his professional development and in their contributions to his work and this book. Bleiberg’s gentle sense of humor is another asset of this work. For example, he writes, “The confusion and contradictions that pervade the psychological world of the adolescent are perhaps surpassed only by the formulations created to explain them” (p. 71). In discussing the lack of research supporting some treatment strategies, he acknowledges, “As the old quip goes, psychoanalytically oriented clinicians have failed to realize that the word ‘data’ is not the plural of anecdote” (p. 151). The first six chapters of the book are devoted to a theoretical discussion about the origins and structures of severe personality disorders. Bleiberg first admits that there is little empirical evidence to support the diagnostic validity of personality disorders in children or their continuity into diagnoses of personality disorders in adulthood. However, he contends that these disorders do not and cannot spring into existence at the age of 18 years. He reviews the early history of psychoanalytic thinking about the etiology and course of borderline personality disorder in children but ultimately suggests that a broader developmental approach is more useful in understanding these youngsters. He then critically reviews the psychoanalytic and developmental theories of attachment. Next, he describes the development of reflective functioning in the context of attachment, explicit and implicit memory, symbolic capacities, identity formation, the ideal self, and a sense of agency. He incorporates the work of Stern, Freud, Mahler, Bowlby, Harlow, BaronCohen, Fonagay, Target, Siegel, Hobson, Winnicott, Britton, Sroufe, Erikson, Vygotsky, and others as he develops a picture of the evolving human personality. Bleiberg emphasizes repeatedly that reflective functioning is the key concept in understanding normal and abnormal personality development. Without adequate reflective-symbolic functioning, “the capacities for affect regulation, impulse control, self-monitoring and the experience of self-agency” are unlikely to develop appropriately. After reviewing the psychology and neurobiology of trauma, Bleiberg proposes a model of environmental factors, such as trauma, and constitutional vulnerabilities that lead to the development of severe personality disorders in children and adolescents. He reports that loss of reflective functioning during intense emotion, stress, or trauma is normal but temporary and intermittent. Bleiberg suggests that some children actively inhibit their reflective functioning, replacing it with fragmented experiences, under circumstances in which they are overwhelmed and in need of “protective intervention” by an attachment figure. According to Bleiberg, if that protective intervention is consistently not forthcoming, patterns of retreat from reflective functioning and the reliance on defense mechanisms such as projective identification, denial, and splitting are established. Histories of trauma and abuse are more common in youngsters with personality disorders, although the majority of chil-
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 8 , AU G U S T 2 0 0 3
BOOK REVIEWS
dren abused or traumatized do not develop personality disorders. Furthermore, misattuned, abusive attachment figures who are unable to maintain their own reflective functioning in their interactions with their children increase the possible development of a severe personality disorder in their youngsters. Bleiberg feels that certain youngsters, by virtue of their neurobiological make-up, are more prone to difficulties with reflective functioning, affect regulation, and behavioral organization and more vulnerable to the development of a personality disorder. Some readers may be concerned that although highly detailed and heavily cited, Bleiberg’s conceptualizations are nonetheless conjectural. For example, Bleiberg supports Fonagy’s postulations that infants and toddlers actively inhibit reflective functioning because they are aware that “some of their own internal states can trigger terrifying internal states in their caregivers (e.g., a desire to destroy or abandon them)” (p. 96). The notion that infants’ subjective experiences can be objectively well elucidated seems uncertain. Chapters 5 and 6 are finely detailed clinical descriptions of antisocial and narcissistic children and adolescents and borderline and histrionic children and adolescents, respectively. Bleiberg points out the futility of the DSM-IV category of conduct disorders. Focusing on descriptions of behavior reflects the cultural/social climate that emphasizes “retribution rather than rehabilitation” (p. 105). Bleiberg believes that youngsters who are chronic juvenile offenders are youngsters with personality disorders who need assessment and treatment. He reemphasizes that these youngsters turn away from reflective functioning when they experience internal states that trigger the need for attachment, soothing, and desires for closeness. They develop a capacity for numbness and decreased sensation of pain. Bleiberg believes that either their caregivers have reacted to their appeals for closeness with rejection, ridicule, and abandonment or there has been lack of attunement on the part of the caregiver. Two types of aggressive behavior develop: predatory and affectively driven violence. According to Bleiberg, neurobiological disposition, childrearing patterns, and cultural responses to certain behaviors predispose males to more violent and aggressive behaviors. Bleiberg also describes a reconceptualization of narcissism by the field of psychoanalysis. No longer seen as a normal part of development, Bleiberg defines narcissism as the pain engendered by the discrepancy between the ideal self and the mental representation of the self. Gabbard, Kohut, and Kernberg’s conceptualizations regarding personality disorders are also outlined. The next three chapters cover the treatment of children with severe personality disorders. Bleiberg notes that there have been two main strategies in treatment: (1) focusing on the child’s subjective sense of the world as a basis for making changes in coping strategies and behaviors and (2) targeting the child’s behavior by changing the environment, or through medication, behavior modification and family therapies (p. 150). Bleiberg
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 8 , AU G U S T 2 0 0 3
proposes a treatment model that combines these two approaches using “attachment and the development of reflective function as the organizing principle” (p. 150). Throughout the next several chapters, Bleiberg systematically and thoroughly describes and explains the phases of his treatment model from beginning to termination of therapy. He uses vignettes, bullet-pointed lists, and summaries to organize and clarify techniques, goals, pitfalls, and principles of therapies. Bleiberg believes that inpatient or residential facilities are clinically the most advantageous treatment settings for these youngsters. Additionally, he repeatedly emphasizes the vital role of the caregivers in their child’s treatment. He recommends frequent individual therapy, separate parent/caregiver work, parent-child therapy, a modified form of multisystemic therapy, psychoeducational work, addiction group therapy, and problem-solving skills training as necessary components of the treatment. Bleiberg believes that psychoanalytically trained therapists, by virtue of their own intensive therapy and supervision, are ideally suited to work with these youngsters, who are so often frustrating and provocative. Moreover, the relationship with the therapist is essential, not because of the transference/countertransference relationship, but because it is the most conducive to the patient’s ability to acquire and sustain reflective capacity. Bleiberg believes that successful therapy usually entails 1 to 3 years. In chapter 10, Bleiberg makes his case for the need for residential treatment for children with severe personality disorders. He believes that effective treatment of these youngsters entails integration of every aspect of their lives into a treatment milieu, the crucial aspect of which is the set of relationships with the treatment team. The psychodynamic–developmental model that Bleiberg espouses claims to address the root psychological causes of personality disorders and to provide the optimal format for treatment by creating Winnicott’s “holding environment,” an attuned environment, Gunderson’s “involved interactive environment” and Winnicott’s “facilitating environment” (pp. 246–247). Bleiberg discusses the economic issues that have decimated this kind of treatment, as well as the factors that have prevented proponents of this treatment model from demonstrating its efficacy. One note of consternation to readers may be Bleiberg’s assertion that the pressure to demonstrate efficacy of treatment is primarily the purview of payers whose goal it is to reduce health care costs. Many readers may think that demonstrated efficacy of treatment is a highly desired goal and value of all scientists and physicians. However, Bleiberg, despite his reliance on clinical judgment, does urge “rigorous outcome measurement, careful monitoring of quality of care, and experimental strategies…[to] improve the internal validity of naturalistic approaches” (p. 227). As much as Bleiberg emphasizes the need for residential treatment, he also stresses the critical role of “wraparound” and community-based services. Although not specifically delineated, readers may infer that residential treatment must therefore be provided within the community in which the 1005
BOOK REVIEWS
patient and his/her family live in order to be truly integrated and effective. The book closes with a chapter on pharmacological treatment. Bleiberg endorses this treatment strategy based on the evidence that neurobiological vulnerabilities contribute to the development and maintenance of personality disorders. Modulation of neurotransmitters via medications is a logical tool in the comprehensive treatment model Bleiberg espouses. Bleiberg summarizes the work of others and includes algorithms that have been devised by others, including Davanzo and McCracken’s work on bipolar disorder and intermittent explosive aggression, Texas Children’s Medication Algorithm for affective dysregulation-depression by Hughes and colleagues, and Texas Children’s Algorithm for ADHD by Pliszka’s group. The chapter includes a discussion of the pros and cons and combining or separating the roles of therapist and psychopharmacologist. Despite numerous strengths, some aspects of this book are disquieting. The theoretical constructs upon which it is based
1006
are conjectural and not easily validated. Reliance on clinical judgment over outcome-based evaluation of efficacy does not follow the author’s earlier exhortation to use data instead of anecdote. In reality, because of financial and insurance constraints, the treatment model proposed is available to only a small segment of the population. Wraparound and community services cannot be effectively integrated with inpatient and residential care unless all of these service modalities are widely available in most communities. Current economic, social, and political factors continue to heavily negatively impact our ability to care for these severely impaired and highly challenging patients. Diane Treadwell-Deering, M.D. Texas Children’s Hospital, Houston DOI: 10.1097/01.CHI.0000046904.27264.3F Note to Publishers: Books for review should be sent to Andrés Martin, M.D., M.P.H., Yale Child Study Center, 230 South Frontage Road, P.O. Box 207900, New Haven, CT 06520-7900.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 8 , AU G U S T 2 0 0 3
Despite the above absence of critical information regarding the evaluation and treatment of ADHD, this book is an indispensable Spanish-language resource offering essential guidance for mental health professionals, parents, and teachers facing the challenges of children with ADHD. Because clinical examples to illustrate the applicability of topics under discussion emphasize Spanish-speaking families and their children, this book is particularly recommended for mental health professionals providing clinical services to Latino/Hispanic children with ADHD. Freddy A. Paniagua, Ph.D. Department of Psychiatry and Behavioral Sciences University of Texas Medical Branch, Galveston DOI: 10.1097/01.CHI.0000046905.27264.76
Treating Personality Disorders in Children and Adolescents: A Relational Approach. By Efrain Bleiberg. New York: Guilford Press, 2001, 348 pp., $40.00 (hardcover). In Treating Personality Disorders in Children and Adolescents: A Relational Approach, Efrain Bleiberg from the Menninger Clinic describes his conceptual framework for the development of severe personality disorders in children and adolescents and the treatment model that is the logical outgrowth of this framework. Bleiberg supports an integrative, developmental approach, including psychoanalytic, cognitive, social-cultural, family systems, and neurobiological perspectives. However, the core concept in Bleiberg’s framework and, therefore, in this book is reflective functioning, “the moment-to-moment ability to grasp the meaningfulness and intentionality of human behavior” (p. 2). The book is organized in two halves: a discussion of how severe personality disorders arise and take form and a systematic treatment approach. One of the greatest strengths of the book is the author’s boundless compassion and respect for these very difficult patients and their families. These attributes are evident throughout the work, in the vignettes Bleiberg supplies, in the descriptions of clinical presentation of these disorders, and in the treatment programs he recommends. In the chapter on beginning treatment, Bleiberg endorses Gunderson’s thoughts on the necessary characteristics for treatment staff. He includes “finding these patients interesting, touching and challenging; believing they can improve; accepting one’s personal significance in the treatment for the patient’s welfare; perceiving the patients— and their caregivers—sympathetically and believing that their behavior has meaning; trusting that one can be helpful; being prepared to persevere despite hints of frustration…” (pp. 158–159). It is abundantly clear that Bleiberg himself possesses these qualities. Moreover, the book is prefaced with the most gracious and touching acknowledgements of Bleiberg’s men1004
tors, colleagues, coworkers, staff, friends, and family. He recognizes their roles in his professional development and in their contributions to his work and this book. Bleiberg’s gentle sense of humor is another asset of this work. For example, he writes, “The confusion and contradictions that pervade the psychological world of the adolescent are perhaps surpassed only by the formulations created to explain them” (p. 71). In discussing the lack of research supporting some treatment strategies, he acknowledges, “As the old quip goes, psychoanalytically oriented clinicians have failed to realize that the word ‘data’ is not the plural of anecdote” (p. 151). The first six chapters of the book are devoted to a theoretical discussion about the origins and structures of severe personality disorders. Bleiberg first admits that there is little empirical evidence to support the diagnostic validity of personality disorders in children or their continuity into diagnoses of personality disorders in adulthood. However, he contends that these disorders do not and cannot spring into existence at the age of 18 years. He reviews the early history of psychoanalytic thinking about the etiology and course of borderline personality disorder in children but ultimately suggests that a broader developmental approach is more useful in understanding these youngsters. He then critically reviews the psychoanalytic and developmental theories of attachment. Next, he describes the development of reflective functioning in the context of attachment, explicit and implicit memory, symbolic capacities, identity formation, the ideal self, and a sense of agency. He incorporates the work of Stern, Freud, Mahler, Bowlby, Harlow, BaronCohen, Fonagay, Target, Siegel, Hobson, Winnicott, Britton, Sroufe, Erikson, Vygotsky, and others as he develops a picture of the evolving human personality. Bleiberg emphasizes repeatedly that reflective functioning is the key concept in understanding normal and abnormal personality development. Without adequate reflective-symbolic functioning, “the capacities for affect regulation, impulse control, self-monitoring and the experience of self-agency” are unlikely to develop appropriately. After reviewing the psychology and neurobiology of trauma, Bleiberg proposes a model of environmental factors, such as trauma, and constitutional vulnerabilities that lead to the development of severe personality disorders in children and adolescents. He reports that loss of reflective functioning during intense emotion, stress, or trauma is normal but temporary and intermittent. Bleiberg suggests that some children actively inhibit their reflective functioning, replacing it with fragmented experiences, under circumstances in which they are overwhelmed and in need of “protective intervention” by an attachment figure. According to Bleiberg, if that protective intervention is consistently not forthcoming, patterns of retreat from reflective functioning and the reliance on defense mechanisms such as projective identification, denial, and splitting are established. Histories of trauma and abuse are more common in youngsters with personality disorders, although the majority of chil-
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 8 , AU G U S T 2 0 0 3
BOOK REVIEWS
dren abused or traumatized do not develop personality disorders. Furthermore, misattuned, abusive attachment figures who are unable to maintain their own reflective functioning in their interactions with their children increase the possible development of a severe personality disorder in their youngsters. Bleiberg feels that certain youngsters, by virtue of their neurobiological make-up, are more prone to difficulties with reflective functioning, affect regulation, and behavioral organization and more vulnerable to the development of a personality disorder. Some readers may be concerned that although highly detailed and heavily cited, Bleiberg’s conceptualizations are nonetheless conjectural. For example, Bleiberg supports Fonagy’s postulations that infants and toddlers actively inhibit reflective functioning because they are aware that “some of their own internal states can trigger terrifying internal states in their caregivers (e.g., a desire to destroy or abandon them)” (p. 96). The notion that infants’ subjective experiences can be objectively well elucidated seems uncertain. Chapters 5 and 6 are finely detailed clinical descriptions of antisocial and narcissistic children and adolescents and borderline and histrionic children and adolescents, respectively. Bleiberg points out the futility of the DSM-IV category of conduct disorders. Focusing on descriptions of behavior reflects the cultural/social climate that emphasizes “retribution rather than rehabilitation” (p. 105). Bleiberg believes that youngsters who are chronic juvenile offenders are youngsters with personality disorders who need assessment and treatment. He reemphasizes that these youngsters turn away from reflective functioning when they experience internal states that trigger the need for attachment, soothing, and desires for closeness. They develop a capacity for numbness and decreased sensation of pain. Bleiberg believes that either their caregivers have reacted to their appeals for closeness with rejection, ridicule, and abandonment or there has been lack of attunement on the part of the caregiver. Two types of aggressive behavior develop: predatory and affectively driven violence. According to Bleiberg, neurobiological disposition, childrearing patterns, and cultural responses to certain behaviors predispose males to more violent and aggressive behaviors. Bleiberg also describes a reconceptualization of narcissism by the field of psychoanalysis. No longer seen as a normal part of development, Bleiberg defines narcissism as the pain engendered by the discrepancy between the ideal self and the mental representation of the self. Gabbard, Kohut, and Kernberg’s conceptualizations regarding personality disorders are also outlined. The next three chapters cover the treatment of children with severe personality disorders. Bleiberg notes that there have been two main strategies in treatment: (1) focusing on the child’s subjective sense of the world as a basis for making changes in coping strategies and behaviors and (2) targeting the child’s behavior by changing the environment, or through medication, behavior modification and family therapies (p. 150). Bleiberg
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 8 , AU G U S T 2 0 0 3
proposes a treatment model that combines these two approaches using “attachment and the development of reflective function as the organizing principle” (p. 150). Throughout the next several chapters, Bleiberg systematically and thoroughly describes and explains the phases of his treatment model from beginning to termination of therapy. He uses vignettes, bullet-pointed lists, and summaries to organize and clarify techniques, goals, pitfalls, and principles of therapies. Bleiberg believes that inpatient or residential facilities are clinically the most advantageous treatment settings for these youngsters. Additionally, he repeatedly emphasizes the vital role of the caregivers in their child’s treatment. He recommends frequent individual therapy, separate parent/caregiver work, parent-child therapy, a modified form of multisystemic therapy, psychoeducational work, addiction group therapy, and problem-solving skills training as necessary components of the treatment. Bleiberg believes that psychoanalytically trained therapists, by virtue of their own intensive therapy and supervision, are ideally suited to work with these youngsters, who are so often frustrating and provocative. Moreover, the relationship with the therapist is essential, not because of the transference/countertransference relationship, but because it is the most conducive to the patient’s ability to acquire and sustain reflective capacity. Bleiberg believes that successful therapy usually entails 1 to 3 years. In chapter 10, Bleiberg makes his case for the need for residential treatment for children with severe personality disorders. He believes that effective treatment of these youngsters entails integration of every aspect of their lives into a treatment milieu, the crucial aspect of which is the set of relationships with the treatment team. The psychodynamic–developmental model that Bleiberg espouses claims to address the root psychological causes of personality disorders and to provide the optimal format for treatment by creating Winnicott’s “holding environment,” an attuned environment, Gunderson’s “involved interactive environment” and Winnicott’s “facilitating environment” (pp. 246–247). Bleiberg discusses the economic issues that have decimated this kind of treatment, as well as the factors that have prevented proponents of this treatment model from demonstrating its efficacy. One note of consternation to readers may be Bleiberg’s assertion that the pressure to demonstrate efficacy of treatment is primarily the purview of payers whose goal it is to reduce health care costs. Many readers may think that demonstrated efficacy of treatment is a highly desired goal and value of all scientists and physicians. However, Bleiberg, despite his reliance on clinical judgment, does urge “rigorous outcome measurement, careful monitoring of quality of care, and experimental strategies…[to] improve the internal validity of naturalistic approaches” (p. 227). As much as Bleiberg emphasizes the need for residential treatment, he also stresses the critical role of “wraparound” and community-based services. Although not specifically delineated, readers may infer that residential treatment must therefore be provided within the community in which the 1005
BOOK REVIEWS
patient and his/her family live in order to be truly integrated and effective. The book closes with a chapter on pharmacological treatment. Bleiberg endorses this treatment strategy based on the evidence that neurobiological vulnerabilities contribute to the development and maintenance of personality disorders. Modulation of neurotransmitters via medications is a logical tool in the comprehensive treatment model Bleiberg espouses. Bleiberg summarizes the work of others and includes algorithms that have been devised by others, including Davanzo and McCracken’s work on bipolar disorder and intermittent explosive aggression, Texas Children’s Medication Algorithm for affective dysregulation-depression by Hughes and colleagues, and Texas Children’s Algorithm for ADHD by Pliszka’s group. The chapter includes a discussion of the pros and cons and combining or separating the roles of therapist and psychopharmacologist. Despite numerous strengths, some aspects of this book are disquieting. The theoretical constructs upon which it is based
1006
are conjectural and not easily validated. Reliance on clinical judgment over outcome-based evaluation of efficacy does not follow the author’s earlier exhortation to use data instead of anecdote. In reality, because of financial and insurance constraints, the treatment model proposed is available to only a small segment of the population. Wraparound and community services cannot be effectively integrated with inpatient and residential care unless all of these service modalities are widely available in most communities. Current economic, social, and political factors continue to heavily negatively impact our ability to care for these severely impaired and highly challenging patients. Diane Treadwell-Deering, M.D. Texas Children’s Hospital, Houston DOI: 10.1097/01.CHI.0000046904.27264.3F Note to Publishers: Books for review should be sent to Andrés Martin, M.D., M.P.H., Yale Child Study Center, 230 South Frontage Road, P.O. Box 207900, New Haven, CT 06520-7900.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 8 , AU G U S T 2 0 0 3