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Article Excerpt
Of challenge to mental health counselor's (MHCs) is the management and treatment of personality disorders. This article will elaborate on the etiological development of Cluster C personality disorders (avoidant, dependant, and obsessive-compulsive), review the self-maintenance functions they provide, and review the cognitive-behavioral, group, and psychodynamic treatments for each of the three Cluster C personality disorders. The central aim of this manuscript is to assist MHCs in better understanding biological and environmental antecedents, treatment interventions, and to ensure that personality dynamics are not overlooked in the treatment process.
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Historically, Axis II Personality Disorders have been recognized as being unresponsive and untreatable (Eskedal, 1998). This category of disorders has been viewed as long-standing and is distinguished by deeply ingrained maladaptive attitudes and behaviors that are ego syntonic, or one with the personality disordered client. These maladaptive beliefs and behaviors are recognized by Seligman (1998) as showing up in at least two of the following areas: perceptions and understandings of oneself and one's environment; expression, nature, range, and appropriateness of emotions; interpersonal skills and relationships; and impulse control. The attitudes, beliefs, and behaviors of the personality disordered individual are usually rigid and inflexible, causing significant impairment in the life of the affected individual.
Traditionally, the treatment of the personality disorders was relegated to the psychodynamic approaches and long-term psychotherapy was considered the treatment of choice (Kernberg, 1996; 2001). Generally, the goal was to change the character structure or life style; however, the outcomes were mixed even among those highly motivated for change (Eskedal, 1998). Treatment methods today differ in that the approach is more focused and structured, with the therapist taking a more active role in the therapy process (Millon, 1996; Pretzer & Beck, 1996).
As recognized by Millon (1996), personality disorders lend themselves to a three-category classification with regard to treatability, analogous to the DSM-IV-TR (APA, 2000) diagnostic categories: Cluster A (paranoid, schizoid and schizotypal), viewed as the treatment resistant category, is believed not likely to benefit or accept change; Cluster B (antisocial, borderline, histrionic, and narcissistic), viewed as the treatment with mixed results group, is often viewed as possessing both treatable and untreatable qualities depending upon the individual; and Cluster C (avoidant, dependant, and obsessive-compulsive), viewed as the treatment responsive category, is believed to have a high amenability.
This paper focuses on Cluster C, which represents behaviors manifested in anxious or fearful patterns and includes: avoidant personality disorder (AvPD), dependent personality disorder (DPD), and obsessive-compulsive personality disorder (OCPD). In the past, personality disorders were explained almost exclusively from a psychodynamic perspective. Most language used to conceptualize personality disorders is in terms of "character language," such as anal character. Despite biological tendencies in the field that emphasized temperament, the psychological tradition that emphasized character was utilized for most of the 20th century (Sperry, 1995). Currently, a paradigm shift has altered the field's perspective on personality disorders, which are now viewed as resulting from a combination of biological, psychological, and social factors (Sperry, 1995). It is recognized that personality disorders represent an enduring pattern of thinking, feeling, and behaving that is relatively stable over the life cycle, beginning in adolescence or early adulthood and continuing on throughout the life cycle. Over time, this maladaptive life-style places the individual at odds with his or her social and cultural environment, leading to distress and/or impairment (Eskedal, 1998).
According to Seligman (1998), Cluster C personality disorders involve the least dysfunction, deeming them more treatable than other personality disorders. Additionally, individuals with Cluster C personality disorders are usually aware of their psychopathology, desire change, and are willing to undergo treatment. Individuals diagnosed with Cluster C personality disorders also have the best outcome with every type of short-term psychotherapy (Magnavita, 1997). Thus, in an era where the number of sessions and amount of time MHCs have to dedicate to their clients is limited, short-term techniques may often surface as the treatment of choice. Despite the fact that these personality disorders have been recognized as being the most responsive to psychological treatment, a dearth of literature exists. This paper elaborates on the etiological development and maintenance of the Cluster C personality disorders, in addition to providing an overview of cognitive-behavioral, group, and psychodynamic treatments for each of the three categories.
AVOIDANT PERSONALITY DISORDER (AVPD)
Etiology
Biological predisposition.
It is commonly believed that biological factors set the foundation for personality while environmental factors shape the form of their expression along a reaction range. In the case of AvPD, the evidence of major biogenic influences in its etiology and development is speculative (Millon & Davis, 2000). However, there is some evidence that a timid infantile temperament may predispose an individual to avoidant patterns of behavior. Kantor (2003) believed that this inherited tendency to be shy is the result of overstimulation or an excess of incoming information, thus, socially timid children display heightened sympathetic reactivity to various environmental changes. Furthermore, this pattern of sympathetic sensitivity has been observed in socially timid children as young as 2 years of age and has been found to be stable throughout childhood (Bartholomew, Kwong, & Hart, 2001). Timid individuals cannot handle an excess of incoming information; therefore, they withdraw from the situation as a self-protective measure.
Biological substrates exist within AvPD as a foundation for the emergence of the disorder itself and full development of AvPD is likely due to significant environmental influences (Millon & Davis, 2000). Biological predisposition alone is insufficient to account for the emergence of this condition suggesting that environmental factors may transform the predisposition into the longstanding behavioral pattern (Benjamin, 2003).
Environmental influences.
Developmentally, individuals diagnosed with AvPD began with adequate nurturance and social bonding, laying the foundation for a continued desire for social contact and encouragement. Despite an adequately nurturing environment, individuals diagnosed with AvPD were often subject to relentless parental control with regard to creating an impressive social image (Benjamin, 2003). Thus, they experienced demands to be admirable in the eyes of their parents, and if they did fail, they were subject to degrading mockery for their imperfections and shortcomings. As a result, they became socialized to perform adequately and manage an appropriate impression while avoiding occasions for embarrassment or humiliation (Sperry, 1995).
Psychodynamic theorists see AvPD behavior as being driven by the shame of not measuring up to their ego ideal. These self-effacing attitudes that develop out of a fear of parental and peer rejection give rise to the following self-perpetuating, avoidant tendencies: (1) hypersensitivity to rejection and a tendency to misread a neutral or even...
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