Book Review
Child and Adolescent Psychiatry
Treating Personality Disorders in Children and Adolescents: A Relational Approach. Efrain Bleiberg. New York: The Guildford Press; 2001. 348 p. US$38.00.
Reviewer
rating*: Very Good
Review by: Nasreen Roberts, FRCPC
Kingston, Ontario
I began this review after my resident had made an abortive effort at reading this book. My skepticism about the controversial title resulted in curiosity about the content. For those who disagree with diagnosing children and adolescents with personality disorders, Bleiberg makes a convincing case against the arbitrary DSM age cut-off for these disorders. Most clinicians and researchers who work with this population are aware that severe personality disorders have their genesis and developmentally consistent expression during childhood and adolescence. What confounds us, however, is that some children and adolescents are resilient to the same etiologic factors and environmental insults.
After reading the introduction, my skepticism was replaced with joy at finding a book that truly harks to a bygone age of exquisitely descriptive yet lucid prose. This was combined with scholarly presentation of all aspects of the biopsychosocial progress on the subject over the last century . Only in the 21st century is it possible to come across a book that comprehensively covers divergent theoretical explanations, each with its own specific language and adherents.
The first 6 chapters provide a historical account of the etiologic conceptualization of the development of severe personality disorders. These chapters cover 70 years of clinical and research study on factors affecting the development of normal and pathological personality. In a truly modern eclectic tradition, the author, a devout training analyst, demonstrates equal interest in research pertaining not only to dynamic theories but also to the latest in neurobiology and pharmacology. Consistently throughout the book, you will find both analytic and neurobiological explanations divided by a mere 20 years on the same page—a faithful adherence to the developments in our thinking. We are given a guided tour with case vignettes that describe early analytic thinking regarding attachment, arriving at our present state of knowledge. One such vignette states, “a starting point of conceptualization of severe personality disorders is the concept of attachment and primacy of social experience in triggering gene expression and developmental outcome.” Further, the vignettes demonstrate that we come “pre-wired” to develop certain types of attachments, which, in turn, dictate our personality development.
The subsequent 5 chapters discuss treatment; we are walked through each stage of therapy from the “Beginning Treatment” to the “ Pharmacological Treatment.”
The psychotherapeutic treatment’s foundation is based on addressing the attachment problems. Recasting psychotherapy from an insight-orientated, conflict-solving modality to an approach based on enhancing reflective function is consistent with the developmental research on resilience and vulnerability. The approach is superbly articulated as follows:
Standing at the convergence of neurobiological, ps ychological and psychosocial perspectives, reflective function, and attachment system from which it springs, can serve as the conceptual glue that joins pharmacological, cognitive and family systems interventions into a coherent and integrated treatment program.
The detailed description of each therapy stage, frequently illuminated by case examples, adds to our understanding while keeping in mind the importance of present sociopolitical economics of health care delivery. Undoubtedly, psychotherapy has arrived in the 21st century when one reads of recent outcome studies and an emphasis on randomized controlled trials for this modality. I found the chapter on residential treatment and continuum of services very thought-provoking. As a director of an adolescent inpatient unit, I, along with my team, face the perennial struggle between mandated short length of stay and our awareness of time required to bring about any change in the most difficult of our patients. There is a discussion about characteristics of a good-enough “holding environment,” together with the various interventions that facilitate treatment. The criteria for admission and discharge are discussed, making it clear that this treatment modality is not a panacea for all, but needs careful weighing of its benefits and costs. Interestingly, the closing chapter of this book on the relational approach to treatment of personality disorders is “Pharmacological Treatment.” Here, the role of pharmacotherapy in facilitating psychotherapy is discussed, including its role in treating neurobiological vulnerabilities—not only dysregulation of affective traits but also of arousal impulsivity traits. Existing algorithms for treating various Axis 1 diagnoses that are comorbid with different personality disorders are reported, such as the algorithm for bipolar disorder and intermittent explosive aggression. Most recent research in children and adolescents informs the role of anticonvulsants and atypical antipsychotics in this population. The chapter ends with practical considerations that highlight changes over 50 years in psychiatrists’ thinking, from the brain–mind dichotomy to the biopsychosocial.
This scholarly work requires prior knowledge of psychoanalytic thinking, phenomenology, theories of development, and clinical experience in child and adolescent psychopathology and disorders.
This is an excellent reference for those who treat these exceedingly difficult children and adolescents and who know the frustration and disappointment, despite Herculean efforts of patience, expertise, and optimism. Residents and trainees who plan a career in psychotherapeutic practice with children and adolescents should use this book as a reference. This book is free of typographical errors and is well priced for a hardcover volume.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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