Restructuring Personality Disorders: A Short Term Dynamic Approach, by Jeffrey J. Magnavita. New York: Guilford Press, 1997.
Reviewed by Jon Frederickson
(Originally posted 29 May 2006)
The goal of short term restructuring therapy is to provide a new structure to the patient’s personality and to resume ego development. Whereas many EDT books focus on rapid access to unconscious emotion, this book focuses on developing the ego capacities which are missing in a fragile patient population. In this book, one learns how to help develop the following ego capacities in the patient: 1) ability to see his defenses; 2) ability to see how his defenses interfere with his goals; 3) how his defenses arise in response to feelings and anxiety; 4) ability to turn against his defenses; and 5) ability to face previously warded off emotions and experiences. We can take these ego capacities for granted with the high functioning neurotic patient. However, with the personality disordered patient these ego capacities are often absent and must be developed through personality restructuring. To do so requires the following steps:
- Help patient see a maladaptive personality trait, pattern, or style, and how it interferes with his goals and creates his symptoms.
- Use past, current, and transference relationships to highlight these patterns.
- Assess whether to pursue comprehensive restructuring or a graded approach. Then select which methods to use: defensive, affective, or cognitive restructuring.
- Bring feelings from core difficulties to the surface and help the patient metabolize them.
- Encourage more adaptive patterns and activities which were previously avoided.
- Process patient’s experience and reaction.
The book includes sections on assessment, diagnosis, typical problems and issues with the personality disordered patient, and flexibility of treatment. But where it makes a unique contribution is on the process and technique of treating personality disordered patients. Separate chapters are devoted to the process and unique difficulties one can encounter with cluster C (treatment refractory), B (mixed results), and A (treatment responsive) patients. Whereas many EDT books focus on the intense experience of affect, this book focuses on helping patients gradually develop the ego capacity for more intense affective experience without channeling their anxiety into cognitive perceptual disruption, somatic pathways, or the smooth muscle system. The book is also unique in its flexibility of approach, its recognition that no one single way or working will be ideal for each patient. Many examples are given of how to make treatment focused, short term, and directive, but flexible and responsive to patient needs and vulnerabilities. For readers accustomed to dramatic cases such as those of Davanloo, you may find these cases bland. This would be a mistaken judgement. There is much subtlety in this smooth, collaborative approach with hard to reach patients, a subtlety which is often more apparent after several readings.