Book Review
Personality Disorders
The Practical Management of Personality Disorder. W John Livesley. New York: Guilford; 2003. 420 p. US$48.00.
Reviewer
rating*: Excellent
Review by: Joel Paris, MD
Montreal, Quebec
In this book, John Livesley, an internationally recognized researcher on personality disorders, describes his clinical approach to patients. Many previous books have been written on the treatment of this challenging population. While other books on this subject have, without much empirical evidence, claimed effective methods, Livesley more humbly recognizes that, although therapy can do much, it is no panacea. Nor does Livesley offer another “brand name” therapy. Instead, as the title states, he suggests an integrative approach:
In many respects the approach to treatment that has been described is similar to what competent therapists do intuitively. This similarity is not accidental. The intent was to systematize eclectic practice and provide a rationale for a pragmatic approach to treatment that seeks to use what works rather than following the requirements of theoretical models that have little empirical support (p 364).
Livesley’s book begins with theoretical considerations, reviewing evidence that personality disorder is an exaggeration of normal traits. The singular in the title is not accidental: Livesley rejects the DSM categorical classification and regards personality disorder as a single entity. Nonetheless, a trait model yields 4 general patterns (emotional dysregulation, inhibitedness, dissocial behaviour, and compulsivity). Reflecting the problems that practitioners of psychotherapy face, many of the clinical examples concern patients with borderline personality disorder.
Livesley considers the etiology of personality disorders within a broad framework wherein neither genetic-temperamental nor psychosocial factors alone can account for their development. While acknowledging research showing that many patients experience childhood adversities, Livesley does not explain personality disorder as a direct consequence of such events. Instead, he emphasizes factors that maintain maladaptive traits in the present. Livesley reviews research showing that personality traits are highly stable and argues that interventions must focus on more changeable aspects.
Livesley’s treatment strategy focuses on alliance building, establishing a frame, offering validation, and obtaining a commitment to change. The book details 5 phases of therapy: safety, containment, control and regulation, exploration and change, and integration and synthesis. Livesley is conversant with psychodynamic principles but does not put great emphasis on exploring the past. Instead, cognitive-behavioural methods such as reframing and learning new adaptive behaviours are prominent in his approach. Unlike other authors, Livesley does not favour continuous treatment over many years; rather, he proposes an option of intermittent therapy provided in 20-session blocks.
This well-written book is full of clinical wisdom and is a superb contribution to the literature. What distinguishes Livesley’s approach is that it is either directly evidence-based or consistent with existing empirical evidence. The price is reasonable, considering the book’s quality. I strongly recommend this book to psychotherapists working with patients who have personality disorders.
*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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