Abstract
This book first attempts the complex undertaking of teasing apart and categorizing the manner in which patients with a variety of personality disorders emerge from particular family and social matrices. In addition to this attempt, the author also looks at which parts of the system should be involved in the assessment and treatment process. In doing this, the author invokes the use of terms such as ‘integrative relational psychotherapy’ and ‘dysfunctional personalogical systems’. These terms have some, but probably limited, usefulness.
Integrative relational therapy appears to be a treatment approach which is admirable in that it links intrapsychic and relational systems and, further, family, individual and social action. The author of this book, a psychotherapist, is Director of the Connecticut Center for Short-Term Dynamic Psychotherapy. He brings together various, wellreferenced perspectives, and provides descriptive words and constructs for understanding, and treating, patients with personality disorder, in a manner that validates what many of us, I suspect, already do. That is, rather than take a unitary approach, a number of us have developed some expertise at looking flexibly at the situation, exploring the family and social context of the patient, and we may, or may not, interchange interventions seeing the individual alone, and/or the individual as part of a marital couple, as part of the family or as part of a system that is exacerbating the patient's problems. This approach modifies the intervention to suit the patient, and to find a treatment ‘match’, rather than expecting all patients to respond positively to a particular treatment modality.
‘Dysfunctional personalogical system’ is rather ‘a mouthful’, and a little more difficult to swallow and digest. It is the author's attempt to label and connect patterns of dysfunctional family systems with subtypes of personality pathology. The personality style is seen as adaptive to the dysfunctional system, but its adaptive value is lost on leaving the original family system. Given that any dysfunctional system or relational diagnosis can provide a wide range of personality disturbances and clinical syndromes in different individuals, it would be surprising if any attempt to categorize ‘dysfunctional personalogical systems’ had more than limited usefulness. In answering his own question, ‘Do these assessments have clinical utility?’ the author does not provide a clear response. The impression is that the assessment does have clinical utility, probably in developing a formulation and treatment plan which are very much tailored to the individual case. It complements the diagnosis of a particular personality disorder. However, the author does make the point that personality is not a fixed entity and is, to some degree, responsive to context. He also makes the point that treatment matching is more an art than a science, and it depends on the range of skills available to the clinician.
The importance of flexibility of treatment is a central message. It is given somewhat repetitively, and in different guises, with the use of numerous clinical examples, only some of which impact as clinically useful to the reader. In some ways, the book is an interesting overview of a wide range of individual, couple and family clinical situations, focused around the construct of personality disorder. One is left with the impression that the author is an experienced, broadly based clinician, with a flair for teaching. Despite this, it is not easy to answer the question ‘For whom is this book useful?’ My impression is that it would be most helpful for expanding the skills of therapists, wanting to understand or treat patients with incapacitating personality disorders, if the therapist is in one of the following three categories: (i) trained in individual psychodynamics with an interest in understanding the importance of systems; (ii) trained in family therapy, with an interest in understanding the importance of the intrapsychic dynamic system; and (iii) influenced by the pressure of managed care to misuse evidence-based, efficiency findings to justify offering only brief, and inexpensive, treatment to all patients.