Discussion Wk 11
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Personality.pdf
Correspondence: Alexander Chapman, PhD, Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 4Z1 Canada. Tel: (778) 782-6932. Fax: (778) 782-3427. E-mail: [email protected]
(Received 7 April 2011 ; accepted 5 May 2011 )
Psychotherapy for personality disorders
KATHERINE L. DIXON-GORDON , BRIANNA J. TURNER & ALEXANDER L. CHAPMAN
Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
Abstract Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identifi ed through searches of electronic databases and classifi ed based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identifi ed. We identifi ed 33 RCTs that evaluated the effi cacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several effi cacious treat- ments and one well-established treatment for this disorder. In contrast, only fi ve RCTs examined the effi cacy of treatments for Cluster C personality disorders, and no RCTs tested the effi cacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the fi rst line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.
Introduction
According to the DSM-IV, personality disorders (PDs) are defi ned as pervasive, non-normative patterns of thought and behaviour which are long- standing, and cause signifi cant impairment in rela- tionships and overall functioning (APA, 2000, p. 685). The DSM-IV includes ten PDs, organized into three clusters: Cluster A disorders, comprising schizoid, paranoid and schizotypal PDs, are charac- terized by odd or eccentric patterns of behaviour; Cluster B disorders, comprising antisocial, border- line, narcissistic and histrionic PDs, are character- ized by dramatic or impulsive patterns of behaviour; and Cluster C disorders, comprising avoidant, dependent, and obsessive – compulsive PDs, are char- acterized by anxious or fearful behaviours. PDs are highly prevalent, with 31 – 45% of psychiatric patients and 10 – 15% of the general adult population meeting criteria for at least one PD (Samuels et al., 2002; Zimmerman & Coryell, 1989).
Personality disorders are associated with substan- tial personal and interpersonal distress, functional impairment, and use of mental health resources (Perry, 1993; Perry & Vaillant, 1989; Skodol, Johnson, Cohen, Sneed, & Crawford, 2007). In fact,
individuals with PDs make up a substantial portion of mental health service consumers (Fyer, Frances, Sullivan, Hurt, & Clarkin, 1988; Markowitz, Moran, Kocsis, & Frances, 1992; Oldham, Skodol, Kellman, & Hyler, 1995; Skodol et al., 1993; Vaughn et al., 2010). Further, early literature documenting limited gains in psychotherapy among individuals with PDs compared to those without PDs (Diguer, Barber, & Luborsky, 1993; Fahy, Eisler, & Russell, 1993; Hardy et al., 1995; Karterud et al., 1992; Shea, Pilkonis, Beckham, & Collins, 1990; Woody, McLellan, Luborsky, & O ’ Brien, 1985) fuelled the assumption that individuals with personality disor- ders may be ‘ untreatable ’ (Lewis & Appleby, 1988).
Although people who hold this assumption have been taken to task with the emergence of mounting evidence for the effi cacy of treatments for PDs, PDs are associated with signifi cant challenges for psycho- therapy. For example, interpersonal, self and identity dysfunction are often hallmark features of various PDs (Livesley, 2003); thus, it is not surprising that the formation and maintenance of a positive working alliance can be a challenging endeavour (Benjamin & Karpiak, 2002; Colson et al., 1985; Muran, Segal, Samstag & Crawford, 1994). Individuals with PDs
International Review of Psychiatry, June 2011; 23: 282–302
ISSN 0954–0261 print/ISSN 1369–1627 online © 2011 Institute of Psychiatry DOI: 10.3109/09540261.2011.586992
Psychotherapy for personality disorders 283
often present to therapy with a variety of challenging behaviours that require attention, including sub- stance use, eating disorders, self-injury, suicidality, and violent or aggressive behaviour (Grant et al., 2004). Moreover, patients with particular PDs pres- ent to treatment with an average of roughly three co-occurring Axis-I disorders (Harned et al., 2009; McMain et al., 2009), making it diffi cult to defi ne and prioritize treatment targets, and to ascertain meaningful ‘ progress ’ . The clinical complexity of these patients can lead to distress, demoralization and burn-out on the part of therapist (Chapman, 2009; Rossberg, Karterud, Pedersen, & Friis, 2008). Individuals with PDs are also more likely to prema- turely terminate therapy compared to those without PDs (Karterud et al., 1992; Skodol, Buckley, & Charles, 1983). Thus, it is not surprising that work with these individuals is sometimes marked by frus- tration on the part of both therapist and patient regarding the rate of therapeutic progress (Murphy & McVey, 2010; Watts & Morgan, 1994).
Research indicates that many mental health pro- fessionals hold a variety of negative beliefs about individuals with PDs, including, for example, that these patients are challenging, attention-seeking, manipulative and even ‘ annoying ’ (Cleary, Siegfried, & Walter, 2002; Fraser & Gallop, 1993; Gallop, Lancee, & Garfi nkel, 1989; James & Cowman, 2007; Lewis & Appleby, 1988). Further, many mental health professionals believe that patients with PDs are less likely to respond to intervention, more likely to pose challenges for clinical management, and are less deserving of mental health resources than indi- viduals without personality disorders (Lewis & Appleby, 1988). Such negative beliefs about indi- viduals with PDs are associated with less empathic and respectful responses, use of punitive sanctions and an overall reduction in adherence to reasonable standards of care (Bowers, 2002; Fraser & Gallop, 1993; Gallop et al., 1989; Watts & Morgan, 1994). Thus, prior to the last 20 years or so, the initial pic- ture regarding psychotherapy for PDs looked gloomy indeed: not only did research suggest that individuals with PDs were among the most treatment resistant patients, but also some clinicians took these fi ndings to heart and often responded to these patients with hopelessness or negativity.
Despite this worrisome beginning, recent evidence supports a much more optimistic outlook regarding the effi cacy and effectiveness of psychotherapy for individuals with personality disorders. In fact, a range of psychosocial treatments seem to be associ- ated with positive outcomes among those with PDs (Livesley, 2003). One review of 15 psychotherapy outcome studies revealed large effect sizes for self- and observer-rated outcomes in both naturalistic and randomized, controlled trials (RCTs) examining
psychotherapy for a variety of PDs (Perry, Banon, & Ianni, 1999). Further, a meta-analytic review of psychotherapy for individuals with Cluster C disorders revealed that these patients signifi cantly improve with cognitive behavioural therapy, psycho- dynamic therapy and social skills training, and these treatment gains are often main tained into follow-up periods of 3 months to 3 years (Simon, 2009). Finally, several RCTs using varied modes and styles of therapy have revealed promising improve- ments with psychotherapy for individuals with PDs (Arnevik et al., 2009; Bateman & Fonagy, 1999, 2008; Giesen-Bloo et al., 2006; Linehan et al., 2006; Svartberg, Stiles, & Seltzer, 2004). Given the evidence that hopelessness or pessimism regarding the ability to treat PDs can negatively impact the care that these patients receive (Bowers, 2002; Gallop et al., 1989; Fraser & Gallop, 1993; Watts & Morgan, 1994), it is crucial that mental health professionals familiarize themselves with this devel- oping literature.
Evaluating psychotherapy
Over the past several decades, increasing attention and effort has been directed toward understanding whether psychotherapy works. To address this ques- tion, researchers undertook a scientifi cally rigorous examination of the effects of psychotherapy for numerous mental disorders, with accumulating evi- dence pointing to positive effects for a variety of therapies (Smith & Glass, 1977). In 1995, Division 12 (Clinical Psychology) of the American Psycho- logical Association began a Task Force on Promo- tion and Dissemination of Psychological Procedures and a Task Force on Psychological Intervention Guidelines in order to further understand and promote the scientifi c support for psychological interventions. A few years later, Chambless and Hollon (1998) published comprehensive guidelines for established that a particular therapy is ‘ empiri- cally supported ’ . Briefl y, Chambless and Hollon (1998) note that, in order to be considered effi ca- cious, a therapy must have been shown to be benefi - cial in at least two carefully controlled studies. Specifi cally, the authors recommend putting the greatest weight on evidence derived from random- ized, controlled trials (RCTs), or trials in which par- ticipants are randomly assigned to receive the therapy in question or to a comparison condition (e.g. wait- ing list, treatment as usual, etc.), with the next great- est weight going to carefully controlled single-case or group experiments. In contrast, uncontrolled studies do not have comparison groups, and non- randomized studies involve non-random assignment to treatment conditions. Studies conducted as RCTs provide the strongest evidence that the observed
284 K. L. Dixon-Gordon et al.
effects are due to the therapy in question, and not to other confounding or common factors. Further, to reduce potential allegiance effects, evidence of a therapy ’ s benefi ts must be found by at least two inde- pendent researchers. If only one study is available to support the therapy or if the studies have all been conducted by the same research team, the therapy may be considered ‘ possibly effi cacious ’ . Chambless and Hollon (1998) also outline a number of metho- dological considerations that should be evaluated in order to determine that the data is of suffi cient qual- ity as to ensure confi dence in the conclusions, and provide guidelines for evaluating effi cacy when there are confl icting results.
In addition to evaluating a treatment ’ s effi cacy, Chambless and Hollon (1998) recommend the consideration of two other criteria: specifi city and effectiveness. To be considered specifi c, the therapy must be effi cacious and must demonstrate superior effects when compared with a control condition that incorporates the nonspecifi c processes of psycho- therapy, such as warmth, attention, expectation of change, and therapeutic rituals and rationales, among other factors (Wampold et al., 1997). A common way to evaluate specifi city is to compare the psycho- therapy under consideration to a ‘ treatment as usual ’ condition, often defi ned as treatment by existing programmes or resources in the community. A more stringent test of specifi city is to compare the therapy against another bona fi de or manualized treatment. For a therapy to be considered effective, a treatment must be shown to produce benefi ts in ‘ the real world ’ of clinical practice, where many of the stringent controls that characterize RCTs may not be present. In addition, Chambless and Hollon (1998) recommend that researchers and clinicians attend to the generalizability, feasibility and cost- effectiveness of therapy in clinical practice.
In this paper, we provide a review of the empirical literature evaluating psychotherapy for PDs. Using PsycINFO and Google Scholar, we searched for papers using the following key words on their own and in combination: personality disorder, Cluster A, Cluster B, Cluster C, psychotherapy, intervention, treatment, randomized controlled trial. Specifi cally, we have focused our review on evidence gleaned from randomized, controlled trials (RCTs) (see Table I). We excluded treatments developed for co-occurring diagnoses (e.g. treatments developed for an Axis I disorder and co-occurring PD). Where no RCTs were found, however, we provide a brief review of uncontrolled or case studies. Although not reviewed here, it is important to note that a wealth of naturalistic and case studies have evaluated therapy outcomes in PDs, also suggesting promise for various psychological approaches.
Evidence-based treatments for personality disorders
Unlike the Axis I psychotherapy literature, which often focuses on the evaluation of the effi cacy and effectiveness of particular therapeutic approaches within discrete diagnostic groups (e.g. CBT for depression, prolonged exposure for PTSD), much of the literature on psychotherapy for Axis II disorders examines the effi cacy of a therapeutic approach for individuals who meet criteria for a range of PDs. This approach makes intuitive sense, given that PDs have high rates of co-occurrence with other PDs (Conklin & Westen, 2005; Critchfi eld, Clarkin, Levy, & Kernberg, 2008; Hillbrand, Kozmon, & Nelson, 1996; Zanarini et al., 1998) and with Axis-I pathology (Skodol et al., 2002b; Zanarini et al., 1998). One notable exception to this trend is the case of borderline personality disorder (BPD), for which specialized treatment approaches have been devel- oped. Studies evaluating treatments to reduce crim- inal recidivism often include substantial proportions of individuals with antisocial personality disorder (ASPD), given the high prevalence of ASPD in offender populations (Hart & Hare, 1989); however, few studies have evaluated the treatment of ASPD specifi cally, and few studies of offender treatment explicitly separate fi ndings for those with ASPD versus those without (Duggan, Huband, Smailagic, Ferriter, & Adams, 2007). A few studies have also evaluated the effi cacy of psychotherapy for Cluster C disorders. Thus, we will fi rst review the evidence for the effi cacy of psychotherapy for per- sonality disorders in general; next, we present a review of the effi cacy of therapeutic approaches that have been developed to target-specifi c PDs.
Randomized controlled trials for mixed personality disorders
After a review of the empirical literature, we identifi ed six RCTs that have examined the effi cacy and specifi city of psychotherapy for mixed PDs (cf. Duggan et al., 2007). Across studies, the most common personality disorder diagnoses included borderline (24.4 – 44.4%), avoidant (5.4 – 40.3%), and obsessive – compulsive (16.2 – 37%). Less fre- quent diagnoses included schizotypal, schizoid, dependant, histrionic, antisocial, and narcissistic PDs, although there was considerable variability across studies. Among these studies, psychodynamic therapies were the most frequently examined thera- peutic approach.
Of these studies, two utilized waiting list control conditions (Huband, McMurran, Evans, & Duggan, 2007; Winston et al., 1994). In the fi rst
Psychotherapy for personality disorders 285 T
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2 0 0 8 )
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5 8 %
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1 5 .8
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; D
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A n
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(S T
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te rp
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l p
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s (I
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S o
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en t
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l se
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ty (
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ll i
n f
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em an
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(2 0 0 9 )
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D 1 3 4 (
8 0 .3
%
fe m
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, 2 6 %
d
ro p
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M B
T ,
2 6 .8
%
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p o u
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m
an ag
em en
t,
2 5 .4
% d
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t
1 8 m
o n
th s
P a
ra su
ic id
e; S
er v ic
e u
se ;
G lo
b a
l se
ve ri
ty (
S C
L -9
0 );
D
ep re
ss io
n (
B D
I) ;
G lo
b a
l fu
n ct
io n
in g (
G A
F );
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ci a
l a
d ju
st m
en t
(S A
S );
I n
te rp
er so
n a
l p
ro b
le m
s (I
IP )
(a ll i
n f
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T )
(C on
ti n u ed
)
286 K. L. Dixon-Gordon et al. T
ab le
I .
(C o n
ti n
u ed
)
S tu
d y
D ia
gn o st
ic g
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p S
am p
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re at
m en
t C
o m
p ar
is o n
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u p
D u
ra ti
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P ri
m ar
y o u
tc o m
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v an
W ei
, A
p p
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an d
V
er b
ra ak
(2
0 1 0 )
B P
D 7 9 (
8 6 .1
% f
em al
e) ,
1 6 .5
% d
ro p
o u
t S
T E
P P
S ,
1 7 .5
%
d ro
p o u
t T
A U
, 1 0 .8
%
d ro
p o u
t 1 9 s
es si
o n
s B
P D
s y m
p to
m s
(B P
D -4
0 );
I m
p u
ls iv
it y
(B P
D S
I- IV
); G
lo b
a l
se ve
ri ty
( S
C L
-9 0 );
Q u
a li
ty o
f li
fe (
W H
O Q
O L
-B )
(a ll i
n f
av o u
r o f
S T
E P
P S
)
C ar
te r,
W il lc
o x,
L
ew in
, C
o n ra
d ,
an d
B en
d it
(2
0 1 0 )
B P
D 7 5 (
al l
fe m
al e)
, 3 0 %
d ro
p o u
t D
B T
, 4 7 .4
%
d ro
p o u
t T
A U
� W
L ,
1 1 .4
%
d ro
p o u
t 6 m
o n
th s
S u
ic id
e an
d s
el f-
h ar
m (
L P
Q ,
P H
I) ;
B P
D s
ym p
to m
s (I
P D
E Q
);
D is
a b
il it
y (
B D
Q );
Q u
al it
y o f
li fe
( W
H O
Q U
O L
) (i
n f
av o u
r o f
D B
T )
C la
rk in
, L
ev y,
L
en ze
n w
eg er
, an
d K
er n
b er
gh
(2 0 0 7 )
B P
D 9 0 (
9 2 .2
% f
em al
e) ,
d ro
p o u
ts n
o t
kn o w
n
T F
P D
B T
, su
p p
o rt
iv e
th er
ap y
1 2 m
o n
th s
S u
ic id
al it
y (O
A S
-M );
A gg
re ss
io n
( A
IA Q
); I
m p
u ls
iv it
y (B
IS -I
I) ;
A n
xi et
y (B
S I)
; D
ep re
ss io
n (
B D
I) ;
S o ci
al a
d ju
st m
en t
(S A
S ,
G A
F )
D av
id so
n e
t al
. (2
0 0 6 )
B P
D w
it h
se
lf -h
ar m
1 0 6 (
8 3 .9
6 %
fe
m al
e) ,
d ro
p o u
ts n
o t
kn o w
n
C B
T �
T A
U T
A U
1 2 m
o n
th s
S el
f- h
a rm
( D
S H
I) ;
G lo
b al
s ev
er it
y (B
S I)
; S
ta te
a n
d t
ra it
a n
xi et
y p
o st
t re
at m
en t
an d
s ta
te a
n x ie
ty a
t fo
ll o
w -u
p (
S T
A I)
; D
ep re
ss io
n (
B D
I- II
); Q
u al
it y
o f
li fe
( E
u ro
Q u
o l)
( in
f av
o u
r o f
C B
T �
T A
U )
D o er
in g
et a
l.
(2 0 1 0 )
B P
D 5 2 (
al l
fe m
al e)
, 4 8 .6
% d
ro p
o u
t T
F P ,
3 8 .5
%
d ro
p o u
t T
B E
, 6 7 .3
%
d ro
p o u
t 1 2 m
o n
th s
B P
D s
y m
p to
m s
(S C
ID -I
I) ;
S er
v ic
e u
se (
G er
m an
T H
I) ;
D ro
p
o u
ts ;
S u
ic id
a li
ty ;
S el
f- in
ju ry
; D
ep re
ss io
n (
B S
I) ; A
n xi
et y
(S T
A I)
; G
en er
al p
sy ch
o p
at h
o lo
gy (
B S
I) (
al l
in f
av o u
r o f T
F P
) F
ar re
ll ,
S h
aw ,
an d
W eb
b er
(2
0 0 9 )
B P
D 3 2 (
al l
fe m
al e)
, 1 2 .5
% d
ro p
o u
t S
F T
, 0 %
d ro
p o u
t T
A U
, 2 5 %
d
ro p
o u
t 3 0 g
ro u
p s
es si
o n
s B
P D
s y m
p to
m s
(B S
I) ;
G lo
b a
l se
ve ri
ty (
S C
L -9
0 );
G lo
b a
l fu
n ct
io n
in g (
G A
F )
(a ll i
n f
av o u
r o f
S F
T )
G ie
se n
-B lo
o
et a
l. (
2 0 0 6 )
B P
D 8 6 (
9 3 %
f em
al e)
, d
ro p
o u
ts n
o t
kn o w
n
S F
T T
F P
3 y
ea rs
, 2 s
es si
o n
s p
er w
ee k
D ro
p o
u ts
; B
P D
s y m
p to
m s
(B P
D S
I) ;
Q u
al it
y o f
li fe
( E
u ro
Q u
o l)
; P
sy ch
o lo
g ic
a l
a n
d p
er so
n a
li ty
p a th
o lo
g y (
al l
in f
av o u
r o f
S F
T )
G ra
tz a
n d
G
u n
d er
so n
(2
0 0 6 )
B P
D w
it h
se
lf -h
ar m
2 2 (
al l
fe m
al e)
, 8 %
d ro
p o u
t E
m o ti
o n
r eg
u la
ti o n
gr
o u
p (
E R
G ),
7 .7
% d
ro p
o u
t
T A
U �
W L
, 9 .1
% d
ro p
o u
t 1 4 w
ee ks
S el
f- h
a rm
( D
S H
I) ;
E m
o ti
o n
d y sr
eg u
la ti
o n
( D
E R
S , A
A Q
);
D ep
re ss
io n
a n
d a
n x ie
ty (
D A
S S
) (a
ll i
n f
av o u
r o f
E R
G )
K o o n
s et
a l.
(2 0 0 1 )
B P
D 2 8 (
al l
fe m
al e)
, 2 0 %
d ro
p o u
t D
B T
, 2 3 %
d
ro p
o u
t T
A U
, 1 7 %
d
ro p
o u
t 6 m
o n
th s
S u
ic id
e o r
se lf
-h ar
m (
P H
I) ;
S er
vi ce
u se
( T
H I)
; D
ep re
ss io
n (
B D
I,
B H
S ,
H A
M -D
), A
n g er
( S
T A
X I)
; D
is so
ci at
io n
( D
E S
); D
ro p
o u
t;
B P
D s
ym p
to m
s (S
C ID
-I I)
( al
l in
f av
o u
r o f
D B
T )
L in
eh an
, A
rm st
ro n
g ,
S u
ar ez
, A
ll m
o n
, an
d
H ea
rd (
1 9 9 1 ),
L
in eh
an
(1 9 9 3 )
B P
D a
n d
s u
ic id
e o r
se lf
-h ar
m 6 3 (
al l
fe m
al e)
, 1 5 .9
% d
ro p
o u
t D
B T
, 1 6 .7
%
d ro
p o u
t T
A U
, 5 8 %
d
ro p
o u
t 1 2 m
o n
th s
S u
ic id
e o r
se lf
-h a
rm (
P H
I; R
F L
I) ;
D ro
p o
u t;
D ep
re ss
io n
( B
D I,
B
H S
) (a
ll i
n f
av o u
r o f
D B
T )
L in
eh an
e t
al .
(2 0 0 6 )
B P
D a
n d
s u
ic id
e o r
se lf
-h ar
m 1 0 1 (
al l
fe m
al e)
, 4 1 .5
8 %
d
ro p
o u
ts
D B
T ,
1 9 .2
%
d ro
p o u
t T
B E
, 2 8 .6
%
d ro
p o u
t 1 2 m
o n
th s
D ro
p o
u t;
S er
v ic
e u
se (
T H
I) ;
S u
ic id
e o r
se lf
-h a
rm (
S A
S H
, R
F L
I) ;
D ep
re ss
io n
( H
A M
-D )
(a ll i
n f
av o u
r o f
D B
T )
Psychotherapy for personality disorders 287
M u
n ro
e- B
lu m
an
d M
ar zi
al i
(1 9 9 5 )
B P
D 6 6 (
8 1 %
f em
al e)
, d
ro p
o u
ts n
o t
kn o w
n
In te
rp er
so n
al
gr o u
p t
h er
ap y
In d
iv id
u al
d yn
am ic
p
sy ch
o th
er ap
y 3 0 s
es si
o n
s S
o ci
al d
ys fu
n ct
io n
( O
B I)
; S
o ci
al a
d ju
st m
en t
(S A
S );
D ep
re ss
io n
(B
D I)
, G
lo b
al s
ev er
it y
(H S
C L
-9 0 )
S o le
r et
a l.
(2 0 0 9 )
B P
D 6 3 (
7 7 .8
% f
em al
e) ,
4 6 %
d ro
p o u
ts D
B T
, 3 4 .5
%
d ro
p o u
t S
ta n
d ar
d g
ro u
p
th er
ap y,
6 3 .4
%
d ro
p o u
t
1 3 s
es si
o n
s B
P D
s y m
p to
m s
(B P
R S
, C
G I-
B P
D );
A n
x ie
ty (
H R
S A
);
D ep
re ss
io n
( H
R S
D );
I rr
it a
b il
it y (
B D
I) ;
P sy
ch o ti
ci sm
( S
C L
- 9 0 -R
); G
lo b
al s
ev er
it y
(C G
I; S
C L
-9 0 -R
) (a
ll i
n f
av o u
r o f
D B
T )
T u
rn er
( 2 0 0 0 )
B P
D 2 4 (
7 9 %
f em
al e)
, 3 7 .5
% d
ro p
o u
ts D
B T
, 2 5 %
d
ro p
o u
t C
li en
t- ce
n te
re d
th
er ap
y, 5
0 %
d
ro p
o u
t
1 2 m
o n
th s
D ro
p o
u t;
S er
vi ce
u se
; D
ep re
ss io
n (
B D
I, B
S S
I, H
D R
S );
A n
xi et
y (B
A I)
; G
en er
al p
sy ch
ia tr
ic s
ym p
to m
s (B
P R
S )
va n
d en
B o sc
h ,
V er
h eu
l,
S ch
ip p
er s,
a n
d
va n
d en
B ri
n k
(2 0 0 2 )
B P
D 5 8 (
al l
fe m
al e)
, 5 6 .9
% d
ro p
o u
ts D
B T
, 3 7 %
d
ro p
o u
t T
A U
, 7 7 %
d
ro p
o u
t 1 2 m
o n
th s
D ro
p o
u t;
S el
f- h
a rm
; A
d d
ic ti
o n
s ev
er it
y (A
S I)
( al
l in
f av
o u
r o f
D B
T )
V er
h eu
l et
a l.
(2 0 0 3 )
B P
D w
it h
se
lf -h
ar m
o r
su ic
id e
5 8 (
al l
fe m
al e)
, 4 1 .4
% d
ro p
o u
ts D
B T
, 3 7 %
d
ro p
o u
t T
A U
, 7 7 %
d
ro p
o u
t 1 2 m
o n
th s
S u
ic id
e o r
se lf
-h ar
m ;
D ro
p o
u t
W ei
n b
er g ,
G u
n d
er so
n ,
H en
n en
, an
d
C u
tt er
( 2 0 0 6 )
B P
D w
it h
se
lf -h
ar m
3 0 (
al l
fe m
al e)
, 0 %
d ro
p o u
t M
A C
T �
T A
U ,
0 %
d ro
p o u
t T
A U
, 0 %
d ro
p o u
t 6 –8
s es
si o n
s S
u ic
id e
o r
se lf
-h ar
m (
P H
I, S
B Q
)
C lu
st er
C P
D M
u ra
n ,
S af
ra n
, S
am st
ag ,
an d
W
in st
on (
2 0 0 5 )
C lu
st er
C P
D
(6 6 %
P D
N O
S
2 2 %
A P
D ,
1 0 %
O
C P
D ,
1 9 %
m
u lt
ip le
)
1 2 8 (
5 3 %
f em
al e)
, 3 4 %
d ro
p o u
t B
ri ef
r el
at io
n al
th
er ap
y (B
R T
),
2 0 %
d ro
p o u
t
S T
D P ,
4 6 %
d
ro p
o u
t; C
B T
, 3 7 %
d ro
p o u
t
3 0 s
es si
o n
s D
ro p
o u
ts (
B R
T �
S T
D P
); P
at ie
n t
co m
p la
in ts
( P
T C
); G
lo b
al
se ve
ri ty
( G
A S
; S
C L
-9 0 );
I n
te rp
er so
n al
p ro
b le
m s
(I IP
);
P er
so n
al it
y sy
m p
to m
s (W
IS P
I)
S va
rt b
er g
et a
l.
(2 0 0 4 )
C lu
st er
C P
D
(6 2 %
A P
D ,
3 4 %
D P
D )
5 0 (
5 0 %
f em
al e)
, 0 %
d ro
p o u
t S
h o rt
-t er
m
d yn
am ic
p
sy ch
o th
er ap
y,
0 %
d ro
p o u
t
C B
T ,
0 %
d ro
p o u
t 4 0 s
es si
o n
s G
lo b
al s
ev er
it y
(S C
L -9
0 -R
); I
n te
rp er
so n
al p
ro b
le m
s (I
IP );
P
er so
n al
it y
p at
h o lo
gy (
M C
M I)
A ld
en (
1 9 8 9 )
A P
D 7 6 (
4 4 .7
% f
em al
e) ,
5 %
d ro
p o u
t E
xp o su
re �
so ci
al
sk il ls
t ra
in in
g ,
5 %
d ro
p o u
t
S o ci
al s
ki ll s
tr ai
n in
g ,
0 %
d ro
p o u t; i
n ti
m ac
y fo
cu se
d s
ki ll s,
1 5 %
d ro
p o u
t;
W L
; 0 %
d ro
p o u
t
1 0 w
ee ks
S h
y n
es s
a n
d a
n x ie
ty (
S R
I, S
Q )
(f av
o rs
t re
at m
en t
o ve
r W
L );
F
u n
ct io
n a
l im
p a
ir m
en t
(f av
o rs
t re
at m
en t
o ve
r W
L );
F
re q
u en
c y s
o ci
a l
a ct
iv it
ie s
(f av
o rs
i n
ti m
ac y
fo cu
s o ve
r sk
il ls
o n
ly );
B eh
av io
u ra
l ra
ti n
gs
(C on
ti n u ed
)
288 K. L. Dixon-Gordon et al. T
ab le
I .
(C o n
ti n
u ed
)
S tu
d y
D ia
gn o st
ic g
ro u
p S
am p
le T
re at
m en
t C
o m
p ar
is o n
g ro
u p
D u
ra ti
o n
P ri
m ar
y o u
tc o m
es
E m
m el
ka m
p
et a
l. (
2 0 0 6 )
A P
D 6 2 (
5 1 .6
% f
em al
e) ,
6 .5
% d
ro p
o u
t C
B T
, 9 .5
%
d ro
p o u
t B
ri ef
d yn
am ic
th
er ap
y, 0
%
d ro
p o u
t, W
L ;
1 1 .1
% d
ro p
o u
t
2 0 s
es si
o n
s P
D b
el ie
fs a
n d
a vo
id a
n ce
( P
D B
Q );
A n
x ie
ty (
L W
A S
Q ,
S P
A I)
(a
ll i
n f
av o u
r o f
C B
T )
S tr
av yn
sk i,
B el
is le
, M
ar co
vi ll er
, L
av al
lu ,
an d
E
li e
(1 9 9 4 )
A P
D 2 8 (
4 6 .4
% f
em al
e) ,
d ro
p o u
ts n
o t
kn o w
n
S o ci
al s
ki ll s
tr ai
n in
g in
v iv
o S
o ci
al s
ki ll s
tr ai
n in
g in
c li n
ic 8 s
es si
o n
s D
ro p
o u
t (i
n f
av o u
r o f
in c
li n
ic );
A n
xi et
y
B o
ld i
te m
s w
er e
si gn
ifi c
an tl
y d
if fe
re n
t b
et w
ee n
t re
at m
en t
co n
d it
io n
s. A
A Q
, A cc
ep ta
n ce
a n
d A
ct io
n Q
u es
ti o n
n ai
re ; A
IA Q
, A n
ge r,
I rr
it ab
il it
y, a
n d
A ss
au lt
Q u
es ti
o n
n ai
re ; A
P D
, av
o id
an t
p er
so n
al it
y d
is o rd
er ;
A S
I, A
d d
ic ti
o n
S ev
er it
y In
d ex
; A
U D
IT ,
A lc
o h
o l
U se
D is
o rd
er s
Id en
ti fi
ca ti
o n
T es
t; B
A I,
B ec
k A
n xi
et y
In ve
n to
ry ;
B C
S S
, B
ri ef
C o re
S ch
em a
S ca
le s;
B D
I, B
ec k
D ep
re ss
io n
I n ve
n to
ry ;
B D
I- II
, B
ec k
D ep
re ss
io n
I n ve
n to
ry I
I; B
D Q
, B
ri ef
D is
ab il it
y Q
u es
ti o n
n ai
re ;
B IS
-I I,
B ar
ra tt
I m
p u
ls iv
en es
s S
ca le
; B
P D
, b
o rd
er li n
e p
er so
n al
it y
d is
o rd
er ;
B P
D -4
0 ,
B P
D C
h ec
k L
is t
4 0 ;
B P
D S
I,
B o rd
er li n
e P
er so
n al
it y
D is
o rd
er S
ev er
it y
In d
ex ;
B P
R S
, B
ri ef
P sy
ch ia
tr ic
R at
in g
S ca
le ;
B S
I, B
o rd
er li n
e S
yn d
ro m
e In
d ex
; B
S I,
B ri
ef S
ym p
to m
I n ve
n to
ry ;
B S
P ,
b ri
ef s
u p
p o rt
iv e
p sy
ch o th
er ap
y;
B S
S I,
B ec
k S
ca le
f o r
S u
ic id
al I
d ea
ti o n
; C
G I-
S ,
C li n
ic al
G lo
b al
I m
p re
ss io
n o
f S
ev er
it y;
C IP
, ci
rc u
m p
le x
o f
in te
rp er
so n
al p
ro b
le m
s; D
A S
S ,
D ep
re ss
io n
A n
xi et
y S
tr es
s S
ca le
s; D
B T
, d
ia le
ct ic
al
b eh
av io
u r
th er
ap y;
D E
R S
, D
if fi
cu lt
ie s
w it
h E
m o ti
o n
R eg
u la
ti o n
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Psychotherapy for personality disorders 289
study, investigators compared either short-term psychodynamic psychotherapy or brief adaptive psy- chotherapy, a traditional insight-orientated psycho- analytic approach developed for PDs based on Heinz Hartmann ’ s concept of adaptation, to a wait- ing list control (Hartman & Rapaport, 1958). Par- ticipants in both psychotherapies demonstrated superior outcomes compared with those in the control condition in terms of global functioning (Winston et al., 1994). Brief adaptive therapy also resulted in signifi cantly greater reductions in symp- toms and improvements in social adjustment, com- pared to a waiting list control, whereas short-term dynamic therapy did not yield signifi cantly greater improvement in social adjustment compared to waiting list. In another study of short-term dynamic psychotherapy, investigators randomly assigned 27 patients with PDs to receive dynamic treatment or to a waiting list control (Abbass et al., 2008). Par- ticipants in the treatment condition demonstrated signifi cantly greater improvements compared with the control participants on measures of psychiatric symptoms and interpersonal functioning. Another RCT compared psycho-education and problem solv- ing group sessions (N � 87) to a waiting list control condition (N � 89) for patients suffering from mixed PDs (Huband et al., 2007). Recipients of the inter- vention exhibited signifi cant improvement in prob- lem solving as well as overall functioning, compared with the control condition.
The fi nal three RCTs utilized other experimental treatments as the comparison condition, and none of these studies showed signifi cant differences in out- comes between treatment conditions. For example, one RCT compared 40 sessions of supportive – expressive psychotherapy with open-ended, non- manualized psychodynamic therapy, revealing signifi cant improvement in symptom severity and psychosocial functioning at termination and follow- up in both conditions (Vinnars et al., 2005). The other RCT compared brief supportive psycho- therapy (BSP), a dynamically orientated treatment which focuses on bolstering self-esteem, reducing anxiety, and developing coping skills with short-term dynamic psychotherapy, an approach involving more confrontation and interpretation (Hellerstein et al., 1998). The results did not indicate any differences between treatments on any outcome measures; how- ever, patients in both groups exhibited decreases in severity of presenting complaints and overall psycho- pathology. Only the BSP group demonstrated a decrease in interpersonal problems. Finally, one study utilized a contact control condition, a discus- sion group (Springer et al., 1995). In this study, a dialectical behaviour therapy-based problem-solving group did not differ from the discussion group in
terms of depression symptoms or health providers ’ observations of problem behaviours.
In addition to these RCTs evaluating specifi c psychosocial treatments, a recent RCT compared an 18 week hospital day treatment programme followed by long-term group and individual therapy with outpatient individual psychotherapy for individuals with PDs (Arnevik et al., 2009). Findings from this study revealed that patients in both groups showed signifi cant improvement in psychosocial functioning, interpersonal problems and PD criteria met over the course of treatment, with approximately 40% of patients showing reliable improvement in their global functioning and roughly 30% showing reliable improvement in interpersonal functioning. The lack of signifi cant differences between treatment conditions, however, leaves open the possibility that confounding factors (e.g. time, natural recovery, other medical, psychosocial, or interpersonal sup- port, medication) other than these specifi c treat- ments may have been responsible for these positive outcomes.
Evidence-based treatments for Cluster A disorders
Personality disorders described as involving odd or eccentric characteristics, including extreme distrust of others, detachment from interpersonal interactions, or odd and magical beliefs, fall into the category of Cluster A PDs. The prevalence of Cluster A PDs in the general population is between 1.6 and 4.1% (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Torgerson, Kringlen, & Cramer, 2001), although the rates of these disorders are substantially higher among psychiatric patients (5.6 – 13.2%) (Bornstein et al., 1988; Zimmerman, Rothschild, & Chelminski, 2005). These disorders, particularly schizotypal and paranoid PDs, have been strongly associated with functional impairment and reliance on social welfare (Skodol et al., 2002a; Vaughn et al., 2010). Although psychotherapy has been suggested to be the best treatment option for individuals suffering from Cluster A PDs (Gabbard, 2000; Stone, 1985), startlingly few studies have examined treatment effi cacy for this class of PDs.
Treatments for mixed Cluster A personality disorders
As we did not fi nd any published reports of RCTs specifi c to Cluster A disorders, we will comment here on some preliminary, uncontrolled studies of psy- chosocial treatments for these PDs. In an uncon- trolled study of 132 Cluster A PD patients, including eight schizoid 16 schizotypal and 108 paranoid
290 K. L. Dixon-Gordon et al.
(roughly 25% of the patients dropped out before treatment was complete), patients exhibited some treatment gains, in terms of symptoms, quality of life, and overall functioning (Katterud et al., 2003). In a prospective non-experimental study of different treatment modalities, participants with Cluster A PDs were non-randomly assigned to receive day treatment (average duration of treatment 10.3 months), inpatient treatment (average duration of treatment 8.6 months), or outpatient treatment (average dura- tion of treatment 13.3 months) (Bartak et al., 2011). The treatments themselves were heterogeneous, with 20% of the outpatient treatment in the psychody- namic tradition, 20% of patients receiving cognitive behavioural treatment, and the remainder receiving eclectic or mixed approaches. Results indicated that, compared with recipients of outpatient treatment, patients receiving day treatment and inpatient treat- ment exhibited signifi cantly greater improvements in symptomatology, global functioning, and quality of life. These results, however, must be interpreted in light of the non-random assignment and baseline differences between groups, with the outpatient participants reporting less severe symptoms.
Treatments for schizotypal personality disorder
Schizotypal PD can be distinguished by a character- istic interpersonal remoteness, unusual thinking, discomfort and distress in interpersonal situations, and perceptual and cognitive disturbances. These individuals may have diffi culties within interpersonal relationships, which can carry over into the thera- peutic relationship. These diffi culties may also be manifested by an inability to mobilize social resources to support treatment, further impeding treatment progress.
We found no published reports of RCTs specifi - cally focused on evaluating treatments for schizotypal PD. Uncontrolled studies reveal mixed fi ndings. Some effectiveness studies demonstrate minimal symptom reduction following treatment among patients with schizotypal PD (Karterud et al., 1992; Mehlum et al., 1991; Winston et al., 1994). On the other hand, one prospective effectiveness study found that patients with Cluster A PD demonstrated simi- lar degrees of improvement following typical psychi- atric hospital after-care treatment, compared with Cluster B and C PD patients (Gude & Vaglum, 2001).
Treatments for paranoid and schizoid personality disorders
Patients struggling with paranoid PD tend to be guarded within social interactions, often believe that they are being victimized or mistreated by others,
and also may attribute malevolent intentions to others. The often defensive stance of patients with paranoid PD can interfere with the development of rapport within treatment, and their suspiciousness of others may undercut trust in the therapeutic work. In contrast, schizoid PD is marked by a disin- terest in social interactions, and individuals with this PD are often not responsive to praise or criti- cism. Whereas for other patients, the social interac- tion within the therapeutic relationship may be supportive, the interpersonal closeness of therapy may be stressful for patients with schizoid PD. In addition, patients with schizoid PD may not be highly motivated for treatment. Together, these characteristics present barriers to treatment of both paranoid and schizoid PD.
Consistent with other reviews, we found no pub- lished reports of RCTs examining the effi cacy of treatments for paranoid or schizoid PD (Duggan et al., 2007). Several case studies have evaluated potential treatments for paranoid PD, however, primarily from a cognitive or behavioural perspec- tive. For instance, authors of two case studies described the benefi ts of twice weekly 1- to 2-hour sessions of behavioural treatments for paranoid PD (Turkat, 1985; Turkat & Maisto, 1985). In a briefer treatment, Williams (1988) treated a patient with paranoid PD with 11 sessions of cognitive therapy, reporting higher ratings of appropriate eye contact by the end of treatment, compared with baseline rat- ings. More recently, a published report describing the treatment of a patient suffering from comorbid paranoid and obsessive – compulsive PDs indicated promise for a modifi ed form of dialectical behaviour therapy (Lynch & Cheavens, 2008). Following nine months of treatment, the patient reported decre- ments in depressive symptoms and no longer met criteria for paranoid or obsessive – compulsive PDs.
Evidence-based treatments for Cluster B disorders
The Cluster B PDs have garnered more research on treatment effi cacy than Clusters A and C combined (Duggan et al., 2007). This focus on Cluster B may be in part due to the impulsive, self- damaging behaviours commonly associated with these ‘ dramatic and erratic ’ PDs. Although the focus to date has been on developing effi cacious treatments for Cluster B disorders, other PDs are in need of similar attention.
Treatments for borderline personality disorder
Borderline personality disorder (BPD) is one of the most common PDs, with 2 – 6% of the population
Psychotherapy for personality disorders 291
meeting criteria for this disorder (Grant et al., 2008; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004).
BPD is associated with one of the highest rates of suicide completion of any mental disorder, with rates of mortality by suicide ranging from 3% to 10% (Paris & Zweig-Frank, 2001). Often considered among the most challenging PDs to treat, due to a combination of emotional dysregulation with interpersonal diffi culties and chaotic life events (Chapman, 2009), several studies over the past 20 years have brought considerable hope to those with BPD. Although other treatments for BPD exist, researchers have only evaluated a few of these treat- ments rigorously in RCTs, including dialectical behaviour therapy (DBT), mentalization-based ther- apy (MBT), transference focused psychotherapy (TFP) and schema focused therapy (SFT).
Among these treatment approaches, DBT was the fi rst treatment to be evaluated by an RCT (Linehan et al., 1991). Since this initial trial, DBT has been the subject of the most empirical investigation, and has received the most empirical support among psychosocial treatments for BPD. DBT is a compre- hensive cognitive behavioural treatment, emphasiz- ing a balance of validation and acceptance of the patient with behavioural change in several areas. DBT focuses specifi cally and directly on many of the behavioural problems characteristic of those with BPD, such as suicidal behaviour, self-injury, and other self-destructive behaviours (e.g. disordered eating, substance use problems) through the monitoring and targeting of these behaviours in indi- vidual therapy sessions and the teaching of behav- ioural skills, typically in a group format. DBT typically involves four components: (1) weekly indi- vidual therapy (typically 50 minutes); (2) weekly skills training group (typically 2 hours); (3) access to the patient ’ s individual therapist outside of appoint- ments via telephone; and (4) a consultation team for therapists working with DBT (Linehan, 1993). To date, most studies have evaluated the effi cacy of DBT in outpatient settings (Koons et al., 2001; Linehan et al., 1991, 2006; McMain et al., 2009).
Findings from studies conducted by several independent research teams have indicated the superiority of DBT compared with various control conditions in the treatment of problems characteris- tic of BPD. For instance, DBT results in fewer sui- cide attempts, lower medical severity of suicide attempts and less time in the hospital compared with treatment as usual (Koons et al., 2001; Linehan et al., 1991; Verheul et al., 2003) and non-behavioural treatment by expert clinicians (Linehan et al., 2006). Further, many of these treatment gains persist for at least 12 months following termination (Linehan et al., 1993, 2006). Three RCTs demon- strated reduced treatment drop-out compared to
treatment as usual (Linehan et al., 1991; van den Bosch et al., 2002) and treatment by experts (Linehan et al., 2006). Other studies have also dem- onstrated greater reductions in depression and anxi- ety symptoms, as well as suicidal ideation, among those with BPD compared to treatment as usual (Koons et al., 2001) and compared with client-cen- tred therapy (Turner, 2000). In a recent Australian RCT (Carter, Willcox, Lewin, Conrad, & Bendit, 2010), DBT was compared with treatment as usual for 73 women with BPD. Although there were no signifi cant differences in rates of non-suicidal self- harm and hospitalizations between groups, partici- pants in the DBT condition reported a higher quality of life and less disability, compared with treat- ment as usual. Findings also support the effi cacy of DBT in the reduction of substance use among sub- stance-dependent individuals with BPD (Linehan et al., 1999, 2002). A recent RCT supported the effi - cacy of DBT skills training alone, in comparison with standard group treatment, for reducing psychiatric symptoms and drop-outs in BPD (Soler et al., 2009). A meta-analysis of DBT revealed consistent moder- ate effect sizes for treatment change in self-harm and suicidal behaviours (Kliem, Kroger, & Kosfelder, 2010). Although DBT is current, the only psycho- social treatment that meets criteria for a ‘ well- established ’ treatment for BPD (Chambless & Ollendick, 2001; Robins & Chapman, 2004), recent investigations suggest that outcomes in DBT may not differ from those of other highly structured, validated treatments administered by experts (e.g. Clarkin et al., 2007; McMain et al., 2009).
Mentalization-based therapy (Bateman & Fonagy, 1999) is rooted in attachment theory, and posits that individuals with BPD struggle to understand how their own and others ’ thoughts and emotions infl u- ence their actions. MBT consisted of (1) weekly hour-long individual psychoanalytic psychotherapy; (2) thrice weekly group analytic psychotherapy for one hour; (3) one hour of weekly expressive therapy oriented toward psychodrama techniques; (4) a weekly community meeting; (5) monthly hour-long meetings with case administrators; and (6) monthly medication reviews. RCTs of MBT have examined its effi cacy within a hospital day treatment pro- gramme (Bateman & Fonagy, 1999, 2001). In this context, 18 months of MBT resulted in signifi cant improvement in BPD symptoms, fewer suicide attempts, less use of psychotropic medication, greater likelihood of achieving and maintaining employment and greater psychosocial functioning compared to treatment as usual (consisting of stan- dard psychiatric care, included psychiatric reviews and hospitalization as needed, and biweekly com- munity follow-up) at termination and at 18 month follow-ups. In fact, fi ve years after treatment
292 K. L. Dixon-Gordon et al.
completion, the MBT group demonstrated fewer suicide attempts, less service use, and fewer MBCT recipients met criteria for BPD, in comparison to the treatment as usual group (Bateman & Fonagy, 2008). A subsequent study revealed that outpatient MBT was superior to structured clinical management (Bateman & Fonagy, 2009). Taken together, the evidence suggests that MBT is a possibly effi cacious treatment for BPD, although more research outside of the treatment developers ’ laboratories would shed further light on its utility.
Transference-focused psychotherapy (Clarkin et al., 2007) focuses on improving patients ’ ability to accurately perceive and respond to interpersonal relationships using the relationship between the patient and therapist as the primary source of infor- mation and the context for intervention. Specifi cally, the theory underlying TFP posits that the tendency to ‘ split ’ the perceptions of oneself and signifi cant others into ‘ good ’ and ‘ bad ’ results in signifi cant interpersonal, identity and emotional dysregulation among individuals with BPD (Kernberg, 1996). TFP therapists attempt to address ‘ splitting ’ by analyzing transference in the therapeutic relationship (Clarkin, Yeomans, & Kernberg, 1999). TFP consists of twice weekly individual therapy sessions (typically 50 min- utes each), over three years. In a study of TFP, 104 patients with BPD were randomly assigned to receive one year of TFP or treatment by experienced clini- cians in the community (Doering et al., 2010). In this study, TFP resulted in superior change in BPD symptoms, psychosocial functioning, and sig- nifi cantly fewer inpatient admissions, treatment drop-outs (38.5% versus 67.3%), and suicide attempts. Both groups led to signifi cant improve- ment in terms of depression and anxiety symptoms. In another RCT, patients with BPD were random- ized to receive one year of either TFP, DBT or sup- portive therapy (Clarkin et al., 2007). Both DBT and TFP resulted in signifi cant reductions in suicidality, and no group differences emerged between DBT, TFP, and supportive therapy; however, only the patients in TFP demonstrated a signifi cant decrease in outward directed anger. Based on this evidence, TFP can be considered both an effi cacious and specifi c treatment for BPD.
Schema-focused therapy (Giesen-Bloo et al., 2006; Young, 2004) focuses on modifying mal- adaptive cognitive schemas among individuals with BPD through a variety of cognitive and behav- ioural techniques. The theory is that persons with BPD develop such schemas in the context of adverse childhood events. In one clinical trial of SFT, the treatment involved twice-weekly individ- ual therapy over three years (Giesen-Bloo et al., 2006), while another RCT compared eight months of SFT with treatment as usual for 32 patients with
BPD (Farrell et al., 2009). SFT resulted in sig- nifi cant reductions in BPD symptoms and global severity of symptoms, and 94% of SFT patients no longer met BPD criteria after treatment, compared with 16% in the treatment as usual group (Farrell et al., 2009).
In an RCT comparing SFT and TFP, results revealed that both treatments signifi cantly improved BPD symptoms; however, the drop-out rates were signifi cantly lower in SFT, and improvements in BPD symptoms and quality of life were signifi - cantly greater among patients in SFT (Giesen-Bloo et al., 2006). Together, this research base distin- guishes SFT as both an effi cacious and specifi c treat- ment for BPD.
There are also a few other emerging manualized treatments for BPD. In an RCT comparing indi- vidual psychodynamic therapy to group therapy for 110 patients with BPD, no signifi cant differences between interventions were found (Munroe-Blum & Marziali, 1995), and both groups demonstrated signifi cant improvements on symptom measures following treatment. In a multi-site study in the UK, 106 patients with BPD were randomized to receive one year of treatment as usual or treatment as usual plus CBT (Davidson et al., 2006). The fi nd- ings from this study indicated that the addition of CBT led to signifi cant reductions in suicidal behav- iours. Patients maintained this gain through a six- year follow-up period, and the CBT group went on to have fewer hospitalizations during follow-up, in comparison with the treatment as usual group (Davidson et al., 2010). In another study, manual- assisted cognitive therapy was examined in compar- ison with treatment as usual for patients with Cluster B PDs and history of self-harm (Evans et al., 2009). Six months of treatment resulted in reduced depres- sion symptoms, compared with treatment as usual.
Investigators also have examined another psycho- social treatment for BPD, called Systems Training for Emotional Predictability and Problem Solving (STEPPS). STEPPS is a group treatment that involves psycho-education about BPD, emotion management skills training, and behaviour manage- ment skills training which elicits support of family and friends (e.g. Bos et al., 2010). Thus far, there have been two uncontrolled studies (Black et al., 2008; Blum, Pfohl, St John, Monahan, & Black, 2002) and two RCTs (Blum et al., 2008; Bos et al., 2010) of STEPPS. The uncontrolled studies sug- gested the potential utility of STEPPS for lessening BPD symptoms and improving quality of life. The fi rst RCT, conducted by the treatment developers, found that STEPPS in addition to treatment as usual resulted in improvements in BPD symptoms and reductions in emergency department visits, com- pared with treatment as usual (Blum et al., 2008).
Psychotherapy for personality disorders 293
In addition, STEPPS was tested in an RCT in com- parison with treatment as usual (Bos et al., 2010). STEPPS recipients demonstrated greater reductions from baseline in general psychiatric symptoms and BPD symptoms than the control group, even at a six-month follow-up. No differences were observed in terms of engagement in impulsive or self- damaging behaviours. Although these fi ndings on STEPPS are very promising, it is unclear yet as to whether STEPPS is effi cacious as a standalone treat- ment, as one of the two RCTs described above exam- ined this treatment as an adjunct to treatment as usual. Therefore, STEPPS may be considered possibly effi cacious at present.
Treatments for antisocial personality disorder
Although psychosocial treatment of criminal offend- ers has also received considerable attention in recent literature (e.g. McGuire, 1995), treatment of antiso- cial PD (ASPD) as a disorder in its own right is rarely investigated. ASPD is a disorder diagnosed primarily on the basis of evidence for misconduct and criminal, reckless, or impulsive behaviour that violates the rights of others, and up to 70% of offenders meet DSM-IV criteria for ASPD (Hart & Hare, 1989). Therefore, evidence supporting the effi cacy of inter- ventions reducing criminal recidivism may suggest avenues for intervention for persons with ASPD. It is, however, important to note that a sizeable minor- ity of offenders do not meet criteria for ASPD, and that not all individuals with ASPD will end up in the criminal justice system (Hillbrand et al., 1996). Psy- chopathy is also closely related to ASPD, although psychopathy is generally considered to be a more narrow set of traits and behaviours. Although not recognized as a personality disorder per se in the DSM-IV, psychopathy is an enduring pattern of behaviour, experiences, and conduct and has been subject to dozens of studies of potential etiological and maintaining factors, etc. For the purposes of this review, we limit our review to the literature examin- ing psychosocial treatments for ASPD and psycho- pathy, but we will not consider the broader literature examining treatments to reduce criminal recidivism.
Early evidence suggested that ASPD is generally predictive of poor outcomes in psychotherapy (Gabbard & Coyne, 1987; Rice, Harris, & Cormier, 1992; Woody et al., 1985) and treatment drop-out (Langevin, 2006; Larochelle et al., 2010; Olver & Wong, 2009). Further, troubling evidence that train- ing in the development of empathic skills, although associated with decreased recidivism, may actually increase the ability of an individual to manipulate others and reoffend ( Hare & Hart, 1993) led to the belief that psychopathy is better treated using legal sanctions limiting an individual ’ s freedom. Of
considerable concern, offenders who meet criteria for psychopathy reoffend two to fi ve times more fre- quently than non-psychopathic offenders (Hare, 1996; Hemphill, Hare, & Wong, 1998; Quinsey, Rice, & Harris, 1995).
The possibility of successfully treating ASPD is no longer viewed as the lost cause that it once was (Salekin, 2002). In particular, encouraging data have emerged on the effectiveness of family-based inter- ventions for antisocial youths (Simon, 1998), par- ticularly for multisystemic therapy (MST) (Henggeler et al., 1986). In a group of juvenile offenders (n � 80), multisystemic therapy resulted in reduced behavioural problems, deviant peer association and improved communication within the family compared to standard therapy (Henggeler et al., 1986). More recent studies suggest that juveniles receiving MST also had signifi cantly lower rates of recidivism and re-arrest compared with controls (Bourdin, Schaeffer, & Heiblum, 2009; Henggeler, Melton, & Smith, 1992). The UK National Institute for Clinical and Health Excellence (NICE) guide- lines also recognize that parent training, brief family therapy and functional family therapy may be effec- tive in managing adolescents who are at risk of devel- oping ASPD (NICE, 2009).
Further bolstering optimism, a recent meta- analysis of 42 studies suggested that psychotherapy has positive effects for psychopaths compared (Salekin, 2002). Specifi cally, 60% of subjects showed improvements in psychotherapy, and improvements were signifi cantly greater among individuals receiv- ing psychotherapy compared with controls. Salekin (2002) suggests that cognitive behavioural therapy and psychoanalytic psychotherapy may be particu- larly promising interventions among psychopaths. Although the treatment literature for psychopathy is undergoing signifi cant growth in recent years we identifi ed only one RCT that focused on treatment for ASPD exclusively. This RCT examined the effect of six months of treatment as usual, supplemented with CBT, in comparison with treatment as usual alone for males with ASPD in a community setting (Davidson et al., 2009). These results suggested a trend for CBT to improve outcomes in terms of social functioning and problematic drinking; the authors attributed the lack of signifi cant differences to the relatively small sample size (N � 52). Another two RCTs evaluated treatments for ASPD and con- current substance dependence. In the fi rst RCT, Brooner, Kidorf, King, and Stoller, (1998) com- pared contingency management intervention (CMI) and methadone treatment with standard methadone treatment alone in individuals with ASPD and opiate dependence. Outcomes suggest that both con- ditions resulted in similar improvements in terms of abstinence and psychosocial functioning. Messina,
294 K. L. Dixon-Gordon et al.
Farabee, and Rawson, (2003) investigated the effi - cacy of CMI plus methadone maintenance versus CMI plus CBT plus methadone in individuals with ASPD and cocaine dependence. Results suggested there were no signifi cant differences between groups in terms of abstinence from cocaine over 16 weeks of treatment.
Although the results from these studies are pro- mising, further work is necessary to develop and optimize treatments for ASPD. The dearth of studies on treatment of ASPD is concerning, particularly given the costs to society associated with criminal behaviour. In addition, the types of relevant out- comes to examine among those with ASPD are not always clear. Recidivism, drug and alcohol use (for those with ASPD who have these diffi culties), aggres- sive behaviour toward other people, and other such outcomes may be relevant, but there is also an ele- vated prevalence of suicidal behaviour, depression, and other mental health concerns among those with ASPD (e.g. Black, Gunter, Loveless, Allen, & Sieleni, 2010). These outcomes often are not examined or targeted in treatments for ASPD.
Treatments for narcissistic and histrionic personality disorders
Patients with Narcissistic PD tend towards self- aggrandizement and may be particularly sensitive to how others view them. Histrionic PD is marked by a desire for attention, gregarious behaviour, and expressive emotionality. Patients with either of these PDs may struggle receiving feedback from cli- nicians on maladaptive thinking or behavioural pat- terns, given their level of investment with how others view them. It also can be challenging as a clinician to grasp the patient ’ s emotional experiences, as those with both PDs tend to lack insight into their diffi - culties. Further, persons with histrionic PD tend to express emotions in a dramatic yet superfi cial manner, and those with narcissistic PD may be averse to expressing vulnerable emotions or concerns regarding effi cacy or competence.
Consistent with recent empirical reviews of the literature (Dhawan, Kunik, Oldham, & Coverdale, 2010; Duggan et al., 2007; Verhueul & Herbrink, 2007), we did not identify any extant RCTs that have evaluated the effi cacy of psychotherapy for narcis- sistic or histrionic PDs. Case studies and anecdotal reports often assert that these disorders are very diffi cult to treat due to limited insight into the nature of the patient ’ s problems, tendency to drop out of treatment and strong transference and countertrans- ference issues (Hingley, 2001a and b; Kernberg, 2007; Larochelle et al., 2010; McNeal, 2003; Nicolo, Carcione, Semerari, & Dimaggio, 2007; Vinnars & Barber, 2008). Several case and time-series studies
of psychotherapy for histrionic PD, however, sug- gest that improvement on self-report measures of depression and interpersonal diffi culties may occur in cognitive analytic and functional analytic treat- ments (Callaghan, Summers, & Weidman, 2003; Kellett, 2007).
Evidence-based psychosocial treatments for Cluster C personality disorders
Avoidant PD (APD), dependent PD (DPD), and obsessive – compulsive PD (OCPD) have been categorized within Cluster C, and are described as anxious or fearful personalities. Although the rate of Cluster C PDs is only 10% (Torgerson et al., 2001) in the general population, it is as high as 48 to 72% (Alnaes & Torgerson, 1990) among outpatients. Despite these high rates of Cluster C PDs, however, there are no extant treatments for these diffi culties which have garnered suffi cient evidence to be designated ‘ effi cacious ’ .
The majority of systematic treatment research in this area includes a heterogeneous sample of Cluster C PDs. One RCT compared the effi cacy of 40 weekly sessions of psychodynamic to cognitive therapy for 50 patients diagnosed with Cluster C personality disorders (Svartberg et al., 2004). The results indicated improvements in self-reported per- sonality pathology symptoms, interpersonal diffi cul- ties, and distress, even at a two-year follow-up, and there was no signifi cant difference in any outcome between the psychodynamic and cognitive interven- tions. Increases in insight, however, (as rated by observers) predicted improvement within the psy- chodynamic group, but not within the CBT group (Kallestad et al., 2010). Another RCT compared two forms of dynamic therapy for patients with mixed PDs (predominantly Cluster C PDs, 70%) (Winston et al., 1994). After 40 sessions, patients in both groups dem- onstrated improvements on measures of distress and functioning, which were maintained at an 18-month follow-up (Winston et al., 1994). In an RCT compar- ing short-term dynamic psychotherapy, brief relational therapy, and CBT, there were no signifi cant differ- ences between groups, except that the group receiving brief relational therapy had lower treatment drop-out (20%) compared with short-term dynamic psycho- therapy (46%) (Muran et al., 2005). Furthermore, fi ndings from a meta-analysis of 15 studies suggest that patients with Cluster C personality disorders maintain medium to large effects (generally measured as symp- tom reduction) achieved from pre-treatment to post- treatment over the course of the follow-up periods (ranging from 3 months to 3 years) (Simon, 2009).
There are also several uncontrolled and non- randomized studies which may suggest other treat- ment options for Cluster C PDs. A large-scale
Psychotherapy for personality disorders 295
signifi cant gains were achieved, participants still reported clinical levels of stress and social function- ing following completion of treatment. In this study, the social skills training did not contribute incre- mentally beyond the graduated exposure. A second RCT compared the effectiveness of brief psychody- namic therapy and cognitive behavioural therapy as outpatient treatment for 62 patients with APD (Emmelkamp et al., 2006). Both the brief dynamic treatment and CBT were superior to the waiting list control condition on outcome measures of APD symptoms, as well as symptoms of co-occurring Axis I disorders. Further, the patients receiving CBT demonstrated signifi cantly greater improvements on all primary outcome measures. At follow-up, the CBT group maintained superior scores on Axis II symptoms. Another RCT compared the effi cacy of in vivo skills training to skills training in the clinic among 28 patients with APD (Stravynski et al., 1994). Although there was no signifi cant difference in terms of symptom reduction between the groups, the group receiving in vivo skills training had higher rates of treatment drop-out. These studies suggest CBT incorporating graduated exposure may be a possibly effi cacious treatment for APD.
In addition to these few RCTs, clinicians have documented single case studies of APD. One case study described using a plan analysis approach for treatment planning, involving a functional analysis of behaviours within the context of a collaborative ther- apeutic relationship (Caspar & Ecker, 2008). For this case, the therapist combined social skills train- ing, DBT emotion regulation skills, and cognitive restructuring. This treatment approach resulted in a large improvement in symptoms, such that the patient no longer met criteria for APD by the end of treatment. In another case study, CBT was used to treat APD and social phobia over the course of 27 sessions (Hofmann, 2007), resulting in substan- tial decrements in reported anxiety symptoms. Based on the cognitive conceptualization of APD as result- ing from beliefs of social inadequacy and worth- lessness, leading to avoidance of anxiety-provoking situations (Rasmussen, 2005), one case study out- lined the use of 20-session cognitive therapy for a woman suffering from APD (Mahgoub & Hossain, 2007). In the only case study of psychoanalysis for APD, the effects of fi ve years of psychoanalysis were described as leading to reductions in symptom sever- ity and relational pathology (Porcerelli, Dauphin, Ablon, Leitman, & Bambery, 2007).
In terms of symptoms, there is substantial overlap between APD and generalized social phobia, which also involves pathological avoidance of social situa- tions to reduce fears of negative social evaluation. In fact, research fi ndings suggest that APD and social phobia frequently co-occur (comorbidity rates from
effectiveness study found that hospitalization day programmes yielded signifi cant improvements in symptoms and overall functioning among patients with Cluster C PD (Karterud et al., 1992). Another effectiveness study followed 371 patients with Cluster C PDs who received long-term outpatient (more than 6 months), short-term day hospitaliza- tion (up to 6 months), long-term day hospitalization, short-term inpatient treatment, and long-term inpa- tient treatment (Bartak et al., 2010). All patients showed improvement in terms of psychiatric symp- toms, global functioning, and quality of life. In par- ticular, the patients receiving short-term inpatient treatment exhibited greater gains from treatment compared with the other modalities. The non- random nature of this study, however, prohibits any conclusions to be drawn with regard to the rela- tive effi cacy of these modalities of treatment. Rather, it is important to note that these disorders appear to be treatable in several different real world mental health treatment settings. A brief expressive-support- ive psychotherapy was evaluated for use with 38 patients suffering from APD and OCPD (Barber, Morse, Krakauer, Chittams, & Crits-Christoph, 1997), and found to yield improvements on mea- sures of interpersonal problems. In the only CBT study in this area, 45 patients with agoraphobia and Cluster C PDs were treated with a fi ve-week agora- phobia-focused daily groups in phase one (Gude, Monson, & Hoffart, 2001). The second phase was a six-week personality focused treatment programme with both group and individual sessions. Symptoms of all Cluster C PDs except OCPD, decreased signifi cantly over the course of treatment.
Treatments for avoidant personality disorder
APD is characterized by avoidance of many social situations due to fear of rejection or ridicule by others, and individuals with APD are often hyper- sensitive to social rejection. Thus, these individuals may readily perceive affronts within the therapeutic relationship, or react defensively to perceived slights. Although often motivated for treatment, patients with APD may fear rejection or criticism on the part of the therapist, resulting in a guarded approach to therapy, drop-out, or avoidance of therapy (particularly group therapy).
Of the Cluster C PDs, APD is the most studied in terms of treatment research. Several studies have evaluated the utility of behavioural interven- tions for APD. In one study of 76 patients with APD, both social skills training and graduated expo- sure to interpersonal situations resulted in decreased anxiety, increased satisfaction with social activities, and enhanced work and social functioning among individuals with APD (Alden, 1989). Although
296 K. L. Dixon-Gordon et al.
with treatment of DPD. Links and Stockwell (2004) delineated two cases in which couple therapy was applied to the treatment of DPD. In the fi rst instance, couple therapy did not lead to an ameliora- tion of symptoms, whereas the second case was described as benefi cial for DPD symptoms. Another single case study indicated that a patient with APD, OCPD, and DPD benefi ted from metacognitive interpersonal therapy (MIT) (Dimaggio, Semerari, Carcione, Nicolo, & Procacci, 2007), a treatment which aims to increase patients ’ ability to identify thoughts and emotions within the context of a stable therapeutic relationship (Fiore, Dimaggio, Nicolo, Semerari, & Carcione, 2008).
Summary and discussion
Overall, the research fi ndings we reviewed suggest that there is hope for signifi cant and meaningful changes in the psychosocial treatment of people with a variety of PDs. Preliminary evidence suggests that treatment effi cacy may vary by diagnostic clus- ter. According to one study, individuals with a Cluster C PDs showed the greatest gains with psychodynamic/interpersonal therapy, followed by individuals with BPD (Karterud et al., 1992). Individuals with schizotypal personality disorder appear to show signifi cantly less improvement com- pared to those with BPD (Karterud et al., 1992; Stone, 1983). Meanwhile, patients with avoidant PD seem to benefi t most from behavioural approaches (e.g. Alden, 1989). However, with the exception of BPD, treatments targeting other PDs have not gar- nered suffi cient research attention to qualify as effi - cacious or specifi c (Chambless & Hollon, 1998; Chambless & Ollendick, 2001).
Despite the toll of PDs on the public healthcare system, clinicians, and the individuals struggling with these disorders, there are vast gaps in the treat- ment literature on PDs. In particular, Cluster A PDs are a frequently overlooked mental health problem, for which there are no established psycho- social treatments. This stands in contrast to recom- mendations by experts in the fi eld, who suggest that psychosocial treatments should be the fi rst line of defence for treatment of PDs (Bartak, Soeteman, Verheul, & Busschbach, 2007; De Leo, Scocco, & Meneghel, 1999).
Several factors also make it diffi cult to draw solid conclusions regarding the effi cacy of psycho- social treatments for PDs. Researchers have high- lighted the diversity of treatments as an obstacle to identifying effi cacious treatments (Bateman & Fonagy, 2000). Furthermore, the lack of appropriate or consistent control conditions further hampers existing research. When studies include control
21 – 90%; Heimberg, Holt, Schneier, Spitzer, & Leibowitz, 1993).Therefore, it is not surprising that many of the treatments which have been helpful for patients with APD, including graduated expo- sure, are similarly useful for patients with social phobia (e.g. Ponniah & Hollon, 2008). Conversely, many of the empirically supported treatments for social phobia are likely to be effective in treating patients with APD.
Treatments for obsessive compulsive personality disorder
Obsessive – compulsive personality disorder (OCPD) is characterized by a tendency to rigidly apply perfectionistic standards to themselves and others, and excessive concern with work, both of which interfere with the completion of work and with social interactions. Individuals with OCPD may have dif- fi culty seeing their particular standards as problem- atic, or seeing other viewpoints. Therefore, patients with OCPD may hold ambivalent views towards treatment, resulting in variable motivation.
We did not identify any published RCTs for OCPD, but a few studies have made inroads towards identifying potential treatments specifi c to OCPD. In an uncontrolled longitudinal study for OCPD, 10 patients with treatment-resistant depression and OCPD received weekly 1-hour sessions in cognitive therapy (Ng, 2005). The treatment was based on the cognitive therapy manual for personality disorders (Beck, Freeman, & Davis, 2004). In this treatment protocol, therapists helped patients identify auto- matic thoughts and engage in cognitive restructuring and paid special attention to the development of a strong therapeutic alliance. Patients received an aver- age of 22.4 sessions of cognitive therapy, resulting in a signifi cant drop in depressive symptoms, personal- ity symptoms, and anxiety symptoms. Two case studies identifi ed adaptations of DBT for OCPD, with positive effects (Lynch & Cheavens, 2008; Miller & Krauss, 2007).
Treatments for dependent personality disorder
Dependent personality disorder (DPD) is distin- guished by a chronic tendency to allow others to shoulder most responsibilities, and to subordinate one ’ s beliefs to individuals viewed as more capable. In relationships, individuals with DPD often leave major decision making to their partners. Therefore, partner involvement and change may be warranted when it comes to treatment of DPD.
Similar to the state of OCPD treatment research, no DPD treatment effi cacy research was found. Two case studies described some of the trials involved
Psychotherapy for personality disorders 297
suggest that with 92 sessions approximately 50% of patients would no longer meet diagnostic criteria for a personality disorder, while 216 sessions would be required to achieve remission in 75% of patients. Findings from some more recent studies, however, have suggested that treatment duration is not associ- ated with outcome (e.g. Soler et al., 2009; Stravynski et al., 1994). For instance, briefer treatment packages have been found to be effective for the treatment of avoidant PD (Emmelkamp et al., 2006), suggesting that there may be differences in optimal treatment duration across clusters. Second, a focus on therapeutic alliance seems crucial. Therapeutic alliance is a focus of many effective treatments for PDs (e.g. Linehan, 1993; Lynch & Cheavens, 2008; Ng, 2005). Furthermore, alliance has been linked with treatment success (e.g. Muran et al., 2005). Third, an emphasis on enhancing the accuracy of cognition, particularly within interpersonal contexts, seems to play an important role across treatments for PDs (e.g. Alden, 1989; Bateman & Fonagy, 2000; Linehan, 1993). Finally, another commonality across PD treatments includes a focus on emotions and emotion regulation (e.g. Gude et al., 2001; Linehan, 1992). As future iterations of the DSM result in a reduced number of discrete PD entities, and as we continue to identify common principles of change across treatments for PDs, newer treat- ment advancements might involve unifi ed treatment packages, much like the work by Barlow and colleagues in their unifi ed treatment approach to emotional disorders (Barlow, Allen, & Choate, 2004). Although the development and evaluation of psychosocial treatments for PDs has lagged some- what behind the work on many Axis I disorders, psychosocial treatments are clearly integral in clinicians ’ efforts to help those with PDs to improve their lives.
Take-home points
Despite the historical view of personality disor-(1) ders as refractory conditions, there are several empirically supported psychosocial interventions for these disorders. There is a dearth of research on treatments for (2) Cluster A personality disorders.
Future directions
(1) There is a need for the development of treat- ments for Cluster A personality disorders.
(2) Research should focus on identifying empirically supported principles of change that could map onto the dimensional approach taken to diagnos- ing personality disorders.
groups, manuscripts reporting the fi ndings often lack specifi c descriptions, relying nondescript labels such as ‘ treatment as usual ’ . Moreover, many of the man- uscripts reporting effectiveness studies do not describe the treatments obtained by participants in detail, further impeding the ability to interpret these fi ndings (e.g. Bartak et al., 2011). In addition, the multitude of co-occurring disorders further compli- cates the interpretation of fi ndings from existing PD treatment studies. Finally, the high rates of treatment discontinuation make this research par- ticularly challenging. Therefore, although promising in many ways, the extant PD treatment literature is marked by multiple challenges and inconsistencies across studies.
Despite these obstacles, the fi eld has made large strides in PD treatment over the past several decades. Perhaps most importantly, the development of effective interventions for BPD has demonstrated the possibility that PDs are in fact treatable, even those PDs that are most maligned and considered most refractory (i.e. BPD). Such research brings hope to clinicians and patients alike, and bolsters clini- cians ’ confi dence and willingness to treat PDs more generally.
The upcoming release of the Diagnostic and Statistical Manual of Mental Disorders – fi fth edition (DSM-V) heralds a substantial shift in the diagnostic views of PDs. Although hotly debated, these revi- sions will inevitably infl uence the fi eld of PD research and treatment. Notably, PDs will be approached from a dimensional perspective (in addition to a prototype-matching perspective), in an effort to reconcile the frequent co-occurrence of these disor- ders. The translation of this existing body of PD treatment research to the newly developed diagnostic system will not be an easy transition. A careful exam- ination of existing treatment research may, however, suggest the next step in PD treatment research and development. In particular, it will prove important to match specifi c, empirically supported principles of change (rather than how-to treatment manuals per se) to specifi c dimensions of personality symptoms, resulting in a more fl exible approach to treatment.
As an initial step toward unifi ed principles of therapeutic change, it is useful to consider common- alities cutting across effective PD treatments. Several common principles span effective treatments for PDs. First, longer term therapy may be necessary for the treatment of PDs. Early evidence suggested that longer treatment duration is associated with better outcome for those with PDs (Budman, Demby, Soldz, & Merry, 1996; Hoglend, 1993; Monsen, Odland, & Eilertsen, 1995; Stevenson & Meares, 1992). In their review of outcome studies investigat- ing a variety of therapy styles, Perry et al. (1999)
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Declaration of interest: The authors report no confl icts of interest. The authors alone are respon- sible for the content and writing of the paper.
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