Because of the lack of research support for work on personality disorders and long-term treatment with psychotherapy, the empirical findings on the treatment of these disorders remain based on the case report method and not on clinical trials. On the basis of case presentations, the treatment of choice is psychotherapy aimed at self-development through resolution of conflict and advancement of inhibited developmental lines. The reason for this choice is that good results have been frequently reported, whereas there are few case reports of success with other approaches.

Despite the fact that most successful treatment reports have been from psychoanalytic psychotherapy perspectives, more recent efforts that have involved the use of cognitive-behavioral approaches have also reported the utility of these perspectives on formulation and technique. For this reason, an integrative approach is useful. By integration, I mean the putting together of a reasoned plan that includes selections from all options.

As recommended by Horowitz, one can use in this integrative therapy the basic ground rules from psychodynamic approaches for how to establish a therapeutic alliance, understand and handle various motivational levels of transference, and counteract resistances to change. Cognitive-behavioral means can be employed for identifying irrational cognitions, disruptions of clear conscious representation and expression, and techniques that reinforce the repetition of more adaptive actions. It is important to repeat interpersonal behavioral changes, because repetition in action may be required in order for the patient to change internal schematizations. When this has been accomplished, the patient becomes less consciously attentive to new behaviors and is then more poised and automatic in the use of less maladaptive practices. The patient is also able to deal more effectively with others in rapidly moving social and work situations and becomes capable of both more realistic and more dignified self-appraisals.

Phases of Formulation and Treatment

It is important to conceptualize a self-developmental course that can help the patient improve functioning and prevent future symptomatic flare-ups. In the following subsections, four phases of formulation as linked to treatment techniques are considered. The first of these concerns presenting complaints. The second considers the sometimes explosive shifts in state that may occur in persons with these disorders, and how presenting complaints may vary from one state of mind to another. The third considers the defensive avoidances habitually used by such patients to avoid knowing clearly what is happening in thought, feeling, and action. The fourth phase of formulation and treatment aims at identifying and changing the maladaptive meaning system that leads to repetition of maladaptive interpersonal patterns and impairing degradations of self-esteem. These four levels constitute a method of formulation called configurational analysis.

Before treatment in these four phases is described, a brief recapitulation is helpful. Diagnosis according to DSM-IV criteria does not lead to treatment choices insofar as this disorder is concerned; individualized case formulation of causation rather than description is indicated. Such formulation has to occur in the midst of crises, shifts in emotional state, and urgent demands; it cannot be swiftly accomplished. Thus treatment begins with general approaches and gradually deepens and specifies what is a central focus as formulations can be inferred. These formulations indicate less general, more individualized selections of interventions. The formulations and techniques of intervention are checked for validity and utility by careful observation of recurrent patterns and by appraisal of the effects of interventions in fostering useful change.